WMJ 01 2010

vol. 56
MedicalWorld
Journal
Official Journal of the World Medical Association, INC
G20438
Nr. 1, February 2010
• Medicine and politics – CPME 50 years
• Multi-Drug Resistant TB in prisons
• Cognitive neuroscience
Editor in Chief
Dr. Pēteris Apinis
Latvian Medical Association
Skolas iela 3, Riga, Latvia
Phone +371 67 220 661
peteris@nma.lv
editorin-chief@wma.net
Co-Editor
Dr. Alan J. Rowe
Haughley Grange, Stowmarket
Suffolk IP143QT, UK
Co-Editor
Prof. Dr. med. Elmar Doppelfeld
Deutscher Ärzte-Verlag
Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor Velta Pozņaka
wmj-editor@wma.net
Journal design and
cover design by Jānis Pavlovskis
Layout and Artwork
The Latvian Medical Publisher
“Medicīnas apgāds”, President Dr. Maija Šetlere,
Katrīnas iela 2, Riga, Latvia
Cover painting:
This oil painting, entitled “Rocky Mountains
1936”, hangs at the offices of the Canadian
Medical Association (CMA) in Ottawa. It
was painted by Sir Frederick Banting, who,
along with Dr. Charles Best, discovered insulin
in 1921. Banting, born in Canada in 1891,
was an accomplished artist and may have had
a successful career as a painter were it not for
his work in medicine. He was killed in February
1941 while serving his country in the Second
World War.The painting was donated to the
CMA by his widow, Lady Henrietta Banting.
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Dr. Dana HANSON
WMA President
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Dr. Masami ISHII
WMA Vice-Chairman of Council
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and Planning Committee
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Prof. Ketan D. Desai
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Prof. Dr. Jörg-Dietrich HOPPE
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Dr. Guy DUMONT
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Members
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Dr. Yoram BLACHAR
WMA Immediate Past-President
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Dr. Jens Winther Jensen
WMA Chairperson of the Medical
Ethics Committee
Danish Medical Association
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Denmark
Prof. Dr. Karsten VILMAR
WMA Treasurer Emeritus
Schubertstr. 58
28209 Bremen
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Dr. Edward HILL
WMA Chairperson of Council
American Medical Assn
515 North State Street
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Dr. José Luiz GOMES DO
AMARAL
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Medical-Affairs Committee
Associaçao Médica Brasileira
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Bela Vista, CEP 01333-903
Sao Paulo, SP
Brazil
Dr. Otmar KLOIBER
WMA Secretary General
13 chemin du Levant
France 01212 Ferney-Voltaire
France
World Medical Association Officers, Chairpersons and Officials
Official Journal of the World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
1
Signs are good that the economic downturn is behind us, and the
challenges before us will not allow us to continue lamenting about it.
However, it will be interesting to see whether there are real lessons-
learned from this crisis or whether we all fall back to business as
usual, unable to process those lessons, unable to implement change.
During the UN Climate Change Conference in Copenhagen, in
September of last year, politicians achieved results which, in scien-
tific terms,would be considered as “suboptimal”. Yet their delay will
give us more opportunities to emphasize the health effects of cli-
mate change.To mitigate those effects will be crucial, but our ability
to respond to climate change also must be examined. Regardless
whether we will have to react to the spread of diseases around the
world, the drastic changes to the human habitat in many regions, or
to natural disasters – Haiti has shown that we still can improve. –
The resources that have been leveraged and delivered to help Haiti
are a good sign for global solidarity and we applaud those who have
engaged personally to do relief work in the country. But Haiti also
reminds us how unequally resources, including medical resources,
are distributed in the world and that our efforts to expand the quali-
fied, adequately equipped health work force still have far to go. Nu-
merous countries are in a perpetual state of emergency,without hav-
ing experienced an earthquake or other calamity, and they deserve
our attention and help as well. People are suffering and dying across
the globe. And when some say they never have seen a catastrophe
equal to the one Haiti,maybe it is because we are constantly turning
our eyes away from places like Darfur and certain areas of Sub-
Saharan Africa.
For the last few years we have been examining the question “Why
do physicians go away?” The answers have been plenty, but they all
boil down to the same basic premise: because of poor working and
living conditions and insufficient pay. Still, we see that many of our
colleagues continue to fight the uphill battle every day and remain
on their job, often under staggering conditions. The question we
would like to ask them is “What makes you continue?” Physician
resilience will be one of the interesting topics WMA President. Dr.
Dana Hanson, will help us address this year.
Another under-appreciated problem before us is the growing in-
fluence governments exert on health care, especially with respect
to our professional independence. Diminishing the professional
status of self-governing bodies by taking away sovereign func-
tions and putting them under government direction, or abolishing
obligatory membership in order to weaken them are just a couple
of examples of what we currently observe. If physicians wish to
remain a respected profession with a protected relationship between
ourselves and our patients, then we must act now and with author-
ity. Governments around must not succeed in reducing physicians
to “service providers” or simple technicians who are subject to the
orders handed down by “payers” – whether they are governments
themselves or private insurance companies.
The WMA is committed to continuing our educational work on
Multidrug-Resistant Tuberculosis, which we combine with efforts
to improve infection control, and we will step up together with our
partners in the World Health Professions Alliance against counter-
feit and substandard medicines that threaten the health and safety
of our patients.
It is difficult to predict all that 2010 has in store for us, but it will
not be boring. We have had a few highlights already and there are
more to come, including:
On the occasion of the 126th World Health Organization Ex-•
ecutive Committee Session from 18-27 January, WMA, togeth-
er with our partners in the World Health Professions Alliance,
urged that the draft “Global Code of Practice on International
No time for depression – a busy year ahead for WMA
Editorial
2
WMA news
In order to discuss the implications of the fi-
nancial crisis for health, the World Medical
Association in cooperation with the Latvian
Medical Association will organise the two
days conference on “The Financial Crisis –
Implications for Health Care. Lessons for the
future”. Conference will take place in Riga,
Latvia on 10th and 11th September, 2010.
The financial crisis has affected the econo-
mies of nearly all countries around the
world. While some countries experienced
“only” a recession, some countries are still
in deep recession leading some countries to
factual insolvency. However, now after the
billions invested in rescue packages for fi-
nancial institutions and a first wave of eco-
nomic recovery programmes the situation is
showing some signals of stabilisation. One
of the sectors of economy, which is also suf-
fering is health care. Health care systems in
many countries seem to be rather stable and
only moderately affected while others expe-
rience significant budget cuts, which leads
to terminating essential health care services
in some areas. In the process of economi-
cal recovery it is important to invest also in
health care to keep people healthier so they
can work more productively, which leads to
faster economical recovery. Since the begin-
ning of the crises, analyses of its impact on
the health sector have been undertaken in
many countries and a range of recommen-
dations and strategies has been suggested to
the governments. Clearly, the responses will
vary from country to country. Nevertheless,
strategies will need to combine measures to
protect the health budget and to prioritise
sectors and groups and to preserve and even
strengthen the quality and efficiency of the
health sector performance.
The conference is expected to gather be-
tween 300 and 400 professionals from Eu-
rope, Asia and America. Based on evidence
drawn from international experience and
research, the Conference, with the partici-
pation of health experts and health profes-
sionals,will provide an overview of the major
threats and challenges to the health systems
caused by the economic crisis. Participants
will identify current key problems and chal-
lenges faced by the health systems in Europe
and globally. Speakers at the conference will
outline responses that countries so far have
developed in addressing these problems and
challenges and look into some priority ar-
eas to assess the effect of the economic re-
cession and to explore effective policies in
resolving the main problems created. The
value of this conference will be experience
gained and finding the best possible solu-
tions for leading health care systems out of
the crisis for faster improvement of health
and recovery of economy.
More information about the conference is
available at www.riga-wma.lv .
Rinalds Muciņš,
Latvian former Minister of Helth
WMA Conference in Riga
Recruitment of Health Personnel”be discussed at the next World
Health Assembly.
In Sao Paulo from 1-3 February, assisted by our member orga-•
nization from Brazil, we brought together the most high-profile
international experts to discuss some of the most difficult ethical
issues associated with placebo use in clinical trials.
WMA convened the third Caring Physicians Leadership Course•
with INSEAD – this time at the INSEAD Campus in Singapore
(February 8-13).
The World Health Professions Alliance will discuss regulation of•
the health profession during the second World Health Profes-
sions Conference on Regulation (Geneva February 18-18) and
From 3-4 May, the third Conference on Person Centred Medi-•
cine will gather in Geneva.
The leaders of the nursing, dentistry, pharmacy and medical pro-•
fessions will meet in Geneva the day before the World Health
Assembly to evaluate and celebrate the first 10 Years of our alli-
ance (May 16).
WMA Council will convene in Evian, France from 20-22 May.•
In September (tentative 10-11), in Riga, Latvia, we will examine•
the effects of the global economic crisis on the world’s health care
systems and what we can learn from our experiences.
October 13-16 will bring together the members of the World•
Medical Association for our WMA General Assembly in Van-
couver, Canada.
Dr. Otmar Kloiber, WMA Secretary General
3
WMA news
On November 28th, the Brazilian Medical
Association in partnership with the Univer-
sity of São Paulo Medical School and the
Institute Health and Sustainability, orga-
nized a conference on climate change called
“Doctors for the Environment”.
Dr. Dana Hanson, president of World
Medical Association (WMA), was invited
to open the conference. He spoke about the
need to examine climate change from the
perspective of patient health. “We’re not
here to find out who is guilty or to judge
anybody.We put individuals at the center of
discussions. Why the health of the popula-
tion is not the focus of Cop 15?”. During
the presentation, Dr. Hanson highlighted
points of the Declaration of Delhi, which
was translated into Portuguese and released
during the event by the Brazilian Medical
Association. Finally, he called on Brazilian
doctors to engage with this issue.
The second block of the event began with
a talk by Dr. Paulo Saldiva, head professor
of pathology at the University of São Paulo.
“Although Brazil has advanced legislation
of the environmental point of view, man
was not included”. To Saldiva, there is not
an engagement with human health and this
is largely to blame on doctors. “Few man-
agers understand health. In Brazil, we are
better prepared to deal with hepatitis B or
with H1N1 than, understand the effects of
climate change on health”. The pollution,
according to data presented by Dr. Saldiva,
caused the death of 4 million people last
year in São Paulo, far more people than the
H1N1 outbreak. “Physicians should use the
credibility and their work to do something,
as they may be guilty of the sin of omission
in a near future”.
After an analysis from the perspective of
health, Carlos Nobre, a chief researcher at
the National Institute for Space Research
(INPE), presented an overview of climate
change in terms of the environment. For
him, the changes in climate are the biggest
challenge that humanity has ever faced.“The
Earth’s natural capital is being squandered”.
In a comparison with the economic crisis,
the researcher said that the planet is being
mortgaged to subprime loans. “The amount
of money needed to mitigate some effects of
climate change is less than required to help
the banks.”For him, the planet passed many
points of no return and if the developing
countries cross the line of sustainability the
situation will get even worse. “We need to
invent a new model of development”.
Eduardo Jorge, São Paulo´s Secretary of the
Environment, followed the discussion by
saying that the responsibility is no longer
only on the hands of the more developed
countries.“In all areas we can do something
to reduce the damage”. He presented some
environmental projects that the city of São
Paulo is working on: Construction of en-
ergy plants at landfills to convert methane
into energy, a city´s initiative to reduce the
emission of pollutants through the vehicle
inspection, protection of water sources and
increasing the number of parks.
Helena Fernandes,
Communication Department,
Brazilian Medical Association
Doctors for the environment
The medical profession and governments have
been urged to pay more attention to the issue
of stress and burn out among physicians, ac-
cording to the President of the World Medical
Association.
Dr. Dana Hanson, a Canadian dermatolo-
gist, said that the medical profession must
strive to remove the stigma surrounding
burn out, while governments must address
the problem, since healthy resilient physi-
cians equalled longer professional lives and,
more importantly, more accessible care for
patients.
Dr. Hanson, addressing The Global Forum
of Health Leaders conference in Taipei,
Taiwan, said that according to surveys in
Canada and elsewhere some 45 per cent of
physicians were in an advanced state of burn
out, with an even higher figure in develop-
ing countries.
But why did one physician thrive in his or
her career while another experience stress?
The answer lay in part in being able to man-
age and recover from adversity. Resilience
meant rising to challenges, responding cre-
atively, learning and growing.
Physicians, he said, should not have to
choose between saving themselves and
serving their patients. Many physicians who
were outwardly patient and enthusiastic
were inwardly burning and finding their
work less rewarding. The global shortage of
physicians was leading to chronic overwork
and stress.
Dr. Hanson said that healthy physicians
meant healthier patients, greater satisfac-
tion, safer care and a sustainable work-
force.
Physicians were generally healthy when it
came to tobacco use, and contrary to pop-
ular belief, drug and alcohol use was no
greater in the medical profession than it was
in other occupations.
“Physicians suffering from silent
desperation”, says WMA leader
4
Medical Ethics, Human Rights and Socio-medical affairs
Yet more demands on physicians and their
increasing lack of control were leading to a
silent desperation among physicians. Wom-
en in the profession in particular appeared
to be at greater risk of suicide, and a signifi-
cant proportion of all physicians had symp-
toms of depression and anxiety,according to
surveys.
Dr. Hanson said that the image and profes-
sionalism of physicians, the threat to their
self regulation, patient safety and account-
ability without authority all contributed to
mental stress.
He said it was time the profession’s leaders
and governments recognised these facts and
took action to support physicians, through
national leadership, raising awareness of the
problems and reducing the stigma of burn
out and education.
Nigel Duncan,WMA Public
Relations Consultant
From a European perspective, the debate on
what is commonly (and often mistakenly)
called task-shifting has crystallised around
the European Commission’s recent “Green
Paper” on the European Workforce. The
main drivers for this are seen as the demo-
graphic changes in the population, the in-
creasing use of information technology in
healthcare, and the changing expectations
of patients. The amount of time a doctor is
available to patients is also affected by the
impact of the European Working Time Di-
rective, an increasing proportion of women
doctors, and a change in attitude on the
“work-life” balance that doctors, like other
members of society, should enjoy.
Demographic changes affect both doctors
and patients. Both groups are ageing to-
gether,with a consequent increase in chron-
ic diseases and a reduction in the number of
physicians available to treat them.
One key issue in any debate about how a
workforce should be reconfigured is, essen-
tially – who does what? What tends to get
in the way of such a debate is an impression
that doctors are resistant to change, and
hold on to old patterns of working in or-
der to retain power. This perception is often
difficult to shift, but a more useful and re-
sponsible way of approaching the “who does
what?” question is to start with two prin-
ciples that are unarguable. The first is that
shifting tasks from one group to another has
to be conditional on also shifting the train-
ing. The second is that task-shifting should
never be done for purely financial reasons,
as to do so will undermine care through the
delivery of sub-optimal services.
Another major but variable demographic
factor is migration. Movement of doctors
from Eastern to Western Europe has been
predominantly driven by economic factors.
The EU’s long-term goal must be to convert
that into a two-way migration based on a
desire for professional self-improvement.
The predicted increase in the number of pa-
tients with long-term chronic illness is a di-
rect result of increased longevity and prog-
ress in treating or containing acute illness.
The influences of obesity, smoking, alcohol
excess and income inequalities will long be
with us. Better screening will identify more
treatable disease, and much of this disease
load will be added to the burden faced by
healthcare systems, whose budgets will be
stretched. The depressing evidence from
the work done to date on health inequali-
ties is that much of this healthcare spending
will have a marginal impact on the overall
health of many groups of EU citizens.
Our patients will expect more information,
more involvement in their care, and greater
freedom to be treated in a place – or even a
country – of their choice. The central im-
portance of the doctor/patient relationship
will not change, but improved interoper-
ability between IT systems, greater access
to information and more freedom of choice
will dramatically alter the way this is con-
ducted.
How should the EU and its doctors ap-
proach the way these influences will affect
us? From the European Commission’s
point of view, a large stumbling block will
be the familiar tension between Member
State autonomy and what is often seen as
EU interference. All the countries in the
EU jealously guard their right to run their
healthcare systems; the EU has a role in
“adding value” where it can do things that
member states cannot do alone. Public
health issues such as global warming, and
communicable disease monitoring are ex-
amples of this. The Green Paper’s approach
to a “European” workforce is limited by this
concept of subsidiarity,leaving the Commis-
sion some room for influence in areas such
as professional mobility and cross-border
healthcare. But with increasing mobility of
Task-shifting or task-sharing? – Reflections
from within the European Union (EU)
Michael Wilks
5
Medical Ethics, Human Rights and Socio-medical affairs
patients and doctors, the influence of eco-
nomic migration, and an opening up of the
market for health, can the EU allow itself to
continue to think in terms of twenty-seven
workforces instead of one?
The terms “skill-mix”, “task-shifting” and
“task-sharing” are often deployed without
adequate definition or context. In CPME’s
(Standing Committee of European Doc-
tors) view, tasks can never be “shifted” from
one healthcare professional group to anoth-
er for purely economic reasons, tempting
though this is for governments squeezed
between the twin pressures of financial crisis
and increased demand for care. CPME and
its fellow European Medical Organisations
have always emphasised that the right train-
ing for the task is essential, and that when it
comes to transferring responsibility for any
aspect of care to another professional, there
are two “non-negotiables” to protect patient
safety. The first, as mentioned, is training,
but equally important is that any sharing or
shifting of tasks takes place within the con-
text of a team, in which skills are defined,
and lines of accountability exist.
Here it is important to stress a funda-
mental difference between doctors and all
other healthcare professionals, based on the
concept of the acceptance of risk. Doctors
are trained to accept risk; perhaps the best
practical example of this is the uncertainty
inherent in a list of differential diagnoses a
doctor works through, eliminating one in
favour of another on the basis of experience,
training and investigation. Uncertainty
is a feature of all healthcare provision, but
the risk associated with this is mitigated in
the way much of other health professionals’
work involves the use of protocols.Protocols
will define or limit practice and also risk,
but their existence also demands that when
the limits or boundaries of what a protocol
allows are reached, then the risk has to be
handed on. In most practical scenarios this
will involve a doctor, so while doctors can
work in isolation (although they rarely do),
most other healthcare professionals have to
be based within a team hierarchy. Another
important factor is that doctors and other
health professions whose tasks are shifted
will also need to be confident that other
members of the team to whom they are
shifted do possess the necessary skills.
Apart from creating differences in profes-
sional behaviour, this fact also adds a new
element to the workforce dilemma. High
standards of care, especially in highly spe-
cialised centres, are not usually produced
by individuals but by teams. The levels of
care achieved will be built up over time as
teamwork, experience and training evolve.
There is therefore a need for the preserva-
tion of teams and not just their individual
elements. This provides an opportunity,
through the support that can be given to
professional development, and through
professional migration, for a new approach.
What needs to be developed, rather than
the somewhat woolly concept of an ethical
recruitment policy, is a real and sustainable
transfer of skills, knowledge and experience
between specialist centres.
Information technology (referred to as “E-
Health” in Europe) is transforming health-
care delivery, although we are still in the
foothills of a transforming journey. There
are three main challenges that this revolu-
tion is delivering to patient care. The first is
the quantity (but not necessarily the quality)
of data. The second is how IT systems com-
municate, within and across organisational
and national borders. Thirdly, this informa-
tion needs to be contextualised so that it is
useable in, for instance, providing relevant
information to patients and assisting them
to be better involved in their care. Develop-
ing the last of these offers part of a solution
to the workforce dilemma.
The European Commission’s Green Paper
extended the definition of the workforce to
include carers. One could ask: “why stop
there; why not include patients?” If we are
serious about more patient involvement and
self-management – and we should be – on
principle alone – then information is key.
The electronic patient record will provide
a powerful tool, not just for improving pa-
tient safety by sharing information across
the healthcare team, but in also providing
a route for better monitoring through tele-
medicine, targeted information flows to as-
sist self-management, and (with appropri-
ate consent) the use of data for healthcare
service planning and for research.
We can see these types of developments in
many countries. In Europe their particular
focus is to support cross-border healthcare.
Although the right of free movement is a
fundamental EU principle, creating the op-
portunity for patients to obtain care across
Member States’borders has been limited by
the organisational and financial problems it
poses. However, as patients move around
more, relevant information to support their
care must also be transferable. Large-scale
pilots are being developed in up to twelve
EU member states to test the technical, le-
gal and ethical aspects of sharing electronic
summaries and “e-prescribing”.
There are enormous advantages (and risks)
in these developments. The greatest advan-
tage is in safer patient care, supported by
improved information-sharing. Using the
electronic patient record as a vehicle for en-
hancing information flow to doctors and to
their patients is a clear benefit, but the chal-
lenge will be to “translate” that information
in a way that is useful and relevant.
The obvious risk is that breaches of patient
confidentiality will destroy confidence in the
system, leading to withholding of informa-
tion. At present, doctors are more sceptical
of the risk of data leakage than patients. Pa-
tients see the benefit of not having to repeat
their history to a variety of different health-
care professionals, while doctors are suspi-
cious of unauthorised access for purposes
other than patient care.
In relation to the role of the doctor, the
information revolution opens up access to
6
Emerging disciplines
medical records by a wider number of pro-
fessionals with involvement in the immedi-
ate care of patients. With widening access
will come the desire to take on new roles, so
the central question – “What is a doctor?”–
is not just a theoretical one. In the EU we
will soon be looking at the review of the Di-
rective on the Recognition of Professional
Qualifications (Directive 2005/36). Up to
now, the ability of doctors to move around
the EU has been conditional on possess-
ing relevant qualifications. As the demand
increases for doctors to demonstrate cur-
rent competence, appraisal, revalidation and
licensing are going to appear on the EU’s
agenda. This will sharpen the focus on what
constitutes the core work of a doctor.
Dr. Michael Wilks,
President CPME (2008-2009)
MWilks@bma.org.uk
In the past ten years, resistant forms of
Tuberculosis, and particularly Multi-Drug
resistant Tuberculosis*
(MDR-TB), have
become a health menace of epidemiologi-
cal proportions, recognized as such by all
international medical organisations such
as WHO, CDC, IUATLD, WMA, MSF**
,
and many more. The World Medical As-
sociation, at its Annual Assembly in New
Delhi in October 2009, underlined the im-
portance of this issue by putting it on the
agenda of its Scientific Session***
.
TB specialists around the world have been
and are still debating how best to tackle
MDR-TB and its even more serious de-
rivative, Extensive Drug Resistance (XDR).
Diagnostic procedures, classification of dif-
ferent categories of resistance patterns, and
actual management and treatment of the
disease are among the many priority issues
undergoing constant review.
In prison settings, all the major issues that
constitute “pitfalls” to good TB manage-
ment are enhanced when dealing with
MDR forms of TB [1,2]. A few additional
considerations need to be addressed, taking
* Defined as being resistant to at least Isoniazid (H)
and Rifampicin (R).
������������������������������������������������World Health Organization; Center for Disease
Control and Prevention;International Union against
Tuberculosis and Lung Disease; World Medical As-
sociation; Médecins Sans Frontières (Doctors w/o
Borders).
��������������������������������������������������See the WMA website for additional information
on the Scientific Session: www.wma.net
into account the communications received
at the WMA 2009 Scientific Session, in the
light of the specific constraints encountered
in prisons and other custodial settings.
Three separate (but, of course, linked) issues
are here considered:
diagnosis of TB and its resistant forms,•
and particularly the use of Drug Suscep-
tibility Testing (DST)
individual treatment vs. standardized•
treatment regimens
additional issues specific to custodial set-•
tings
Diagnosis and selection of anti-
TB drugs according to DST
The greatest risk for TB transmission is
posed by patients with undiagnosed or
unrecognized infectious TB [3], hence the
importance of diagnosis of the disease, and
selection of the correct anti-TB drugs to use
for treatment. Both should always be based
on two complementary criteria: first, the
history of previous anti-TB therapy, and
second, reliable DST, meaning testing that
has been subject to quality control according
to internationally approved standards [4].
The taking of the patient history of previ-
ous therapy, is often problematic, and dif-
ficult – if not outright inadequate or even
sometimes totally absent in prison settings.
The reasons for this are more complex than
mere negligence,and are sometimes difficult
to grasp in developed, high-resource coun-
tries, without the many problems described
further on.
As is well-known, the definition of a “new
patient”, as someone who has never taken
any anti-TB drugs, or taken them for less
than 30 days time, is an essential compo-
nent in the diagnostic procedure of “nor-
mal”, i.e. drug-susceptible TB.This is all the
more important for drug-resistant forms of
the disease.
As has been amply described elsewhere [5],
before the passage of at least 30 days, there
is simply not enough time for a sufficient
number of spontaneous mutations to con-
stitute a sufficient population of resistant
forms of Mycobacterium Tuberculosis. It is
therefore essential to have this situation
Multi-Drug Resistant TB in prisons
Hernán Reyes
7
Emerging disciplines
clearly defined at the start. In the best of
scenarios, a health professional, physician
or nurse, may inform the prisoner/patient
about TB disease, and why it is crucial to
have the exact information, and (hopefully)
why any deviant responses may be detri-
mental not only to the patient but also to
fellow inmates and to any visiting family
members.
“Initiation of drug therapy in patients with
proven MDR-TB requires assessment of
the history of treatment as well as meticu-
lous laboratory studies to characterize the
susceptibility of the specific strain.”
Iseman MD. Treatment of Multidrug-
Resistant Tuberculosis. N Eng
J Med 1993; 329: 784-91
In prison settings, inmates may or may not
tell the truth about their history and many
other issues, for different reasons. While
logical reasoning may seem straightforward
enough to health workers unfamiliar with
prisons, custodial settings differ greatly
from the “outside world”. There is a broad
range of factors influencing the way a pris-
oner answers the questions posed to them.
The first obstacles to obtaining quality
patient history relate to the actual health
professional asking the questions. Prisons
in low-resource countries – most often the
very countries with a high prevalence of TB
and also of MDRTB – are often notoriously
understaffed, particularly regarding health
staff. Experience has shown that poorly
paid, insufficiently trained, and, hence,
poorly motivated health staff are not well
equipped for dealing with complex health
issues such as TB – a fortiori resistant forms
of TB. Poor history-taking is a major short-
coming in many prison health services. It is
also still the sad reality in many prison sys-
tems worldwide, that National TB Control
Programs (NTPs) do not visit the prisons in
their country, or, if they do, they most often
do not have a clear picture of the realities
therein.NTPs are sometimes not allowed to
enter prisons, for administrative or security
reasons. Quite often, NTPs have a passive
attitude towards prisons, and tend to ignore
them. Therefore, medical staff working in
the prisons often lack training on “normal”
TB – let alone its resistant forms. Such
medical staff, even prison doctors, often fail
to diagnose tuberculosis because they lack
the proper training and supervision that
would put TB in the forefront of differen-
tial diagnosis of respiratory diseases.
Even those prison systems that have quali-
fied, motivated staff (i.e., that provide ad-
equate salaries and on-going training), are
often, nonetheless, under-staffed. In these
situations, overworked health personnel
simply do not have the time to take an ad-
equate case history for TB cases. Ideally, in
contexts where resistant TB is a reality in
the outside world (and consequently would
need to be actively looked for in prisons),
previous treatment history should be taken
by a highly trained physician. To take an
adequate history of treatment, this person
should know about first and second line
TB drugs; their availability and use in the
country and their adverse effects (so as to
recognize them as required). There should
be sufficient time per patient, even up to
possibly an hour or so, to ensure all aspects
are duly addressed. It has been often sug-
gested that there be at hand a display of the
different pills available in the country (and
their boxes!), so that the physician can pres-
ent the patient with a choice of visual possi-
bilities and increase the likelihood they will
recognize drugs they have taken previously.
As anyone who has worked in most prisons in
developing countries will know, the ideal situ-
ation described above is, unfortunately, merely
wishful thinking, and is not about become a
reality in most prisons of developing countries
any time soon.
An additional issue that may negatively af-
fect treatment decisions is one that can arise
in both low and high-income countries.
Prisoners are not the most cooperative of pa-
tients. For a whole panoply of reasons, from
wanting to obtain perceived “privileges”; to
desiring transferral to hospital; to other con-
siderations of a totally non-health related na-
ture; prisoners may knowingly provide false
information to health staff. Experience from
ICRCTB programmes in different countries
have shown that prisoners can and do give
the answers to the questions that they believe
will lead to the“geographical”****
or categorical
classification that the prisoner has decided
he or she wants – and not according to medi-
cal criteria, which should be the determining
factor.
The need for Drug Susceptibility Testing
hardly requires any justification in the man-
agement of Tuberculosis and its resistant
forms, even though many factors still limit
its widespread use in developing countries
[4; 5]. The difficulties inherent to the delay
in obtaining results, the possible mishaps
in the technical performances necessary,
and the real problems inherent to the ad-
equate interpretation of results have all been
described. The additional complications of
differentiating DST in vitro results from in
vivo treatment realities are yet another ele-
ment the argumentation. *****
In prisons, the first snag regarding DST is
twofold: first the cost; second the training of
lab staff. Monetary considerations should
theoretically no longer be an obstacle, now
thatTB and MDRTB have been recognized
by the WHO and practically all countries
�������������������������������������������������������“Geographically”meaning“beingsenttoaspecific
prison, which the prisoner wants to be sent to, re-
gardless of any health consideration…”
***** 10 years ago, both WMA in its “Declaration of
Edinburgh on Prison conditions and the spread of
Tuberculosis and other communicable diseases”(Oct
2000),and EFMA/WHO in its “Warsaw Statement
on Tuberculosis and Prisons” ( March 2000 ) called
on national medical associations to urge govern-
ments to take urgent action on these issues.
While there has been some progress in influenc-
ing improvement in healthcare and disease control
in hospitals as Dr. Reyes warns the difficulties in
achieving change persist and the need for NMAs to
act remains. ED.
8
Emerging disciplines
as real health emergencies, and given the
availability of financial resources from such
entities as the “Global Fund”(GFATM*
).In
reality, however, prisons are often last on the
priority list for funding of any kind**
.
DST, even for First Line Drugs (FLD),
needs some form of laboratory setup, and
lab staff. Even Sputum Smear Microscopy
(SSM), the basic of basics in TB diagnosis,
requires a lab technician trained to cor-
rectly do a Ziehl-Neelsen stain – and other
staff trained and qualified to read the slides.
DST of course is more complex of course
than SSM, and involves a more significant
investment in both money and training.
While nobody argues that such investments
are not necessary; the point is that prisons
are way behind in developing the adequate
infrastructures, in recruiting and training
adequate staff, and retaining them by pay-
ing them correctly so they do not leave to
go into the private sector. Most impor-
tant: prisons need to create and develop a
working relationship with, and receive sup-
port and supervision from, their respective
NTPs. DST for Second Line Drugs (SLD)
is problematic, difficult, costly and some-
times unreliable in the best of settings – and
would be even more so in prisons.This is all
the more regrettable, as prisons are assured-
ly a high-risk environment for development
of resistant forms of tuberculosis.
Based on ICRC experience working in
prisons in different countries,even adequate
laboratories and trained staff need constant
supervision. In many cases, visibility into
the prison system from outside, and strong
accountability, will also be necessary. There
are many forms of “corruption” that can
occur within the laboratory component,
* Global Fund to Fight AIDS, Tuberculosis and
Malaria
���������������������������������������������������With the exception of high-security prisons, per-
haps, in those countries concerned by the so-called
“war on terrorism”…
It has not yet been considered nor documented
whether TB is a significant worry among such “spe-
cial” inmates…
which have been described elsewhere [2].
However, if the “rigging” of lab results was
considered as a major shortcoming for “nor-
mal TB”, the issue becomes of overriding
importance when the much more deadly
forms of TB, MDR or XDR, are the issue.
The old DOTS acronym, no longer in use,
could be perhaps used to remind local staff
of the need to supervise theobtaining of
sputum:
Directly Observed Taking of Sputum…
To have true and interpretable results
for all patients in MDR-TB cohorts, it is
thus essential that there be no “cheating”
of any kind. Sputum exchanges between
prisoners have now been documented in
many countries and measures to prevent
any such deception. Less straightforward
is the thwarting of “fake” results, obtained
by threats or “arm-twisting” of lab staff or
even medical personnel. This phenomenon
has been observed in ICRC field work, but
is for obvious reasons very difficult to docu-
ment, let alone publish. It is essential how-
ever to keep such possibilities in mind, and
for those responsible for TB programmes
(above all the NTP) to do everything pos-
sible to avoid them.
Individual treatment vs.
standardized treatment regimens
The issue of individual vs. standardized
treatment is an on-going controversy across
the TB realm that also has implications for
the prison setting. For some of the obvious
reasons already outlined above, it will be
much easier to implement a standardized
regimen in a custodial setting. Medical and
health staff, particularly if under-staffed,
will better be able to handle a standardized
regimen. With the advance of MDR and
even XDR TB, there will be understandable
arguments for Individual Treatment Regi-
mens (ITRs) for specific patients. It will
thus be necessary to provide the staff and
training – as well as all the safeguards nec-
essary – for adequate management of these
more complex cases in prisons.
It is in this context that the matter of ad-
equate and direct supervision can be men-
tioned. Directly Observed Treatment
(DOT) is a must in a prison setting. Pris-
oners may decide, for reasons of their own,
either not to take their full prescribed treat-
ment, or to take, “on the sly”, a different
treatment, smuggled in from outside, by
often well-meaning family members. Stan-
dardized treatments often rely on “blister
packs” for observance of adequate posology.
While the system has obvious advantages for
the patient outside prison, the inverse argu-
ment cannot be made for prisoners. Health
staff cannot simply rely on the absence of
the pill in the blister pack to “confirm” ad-
herence to treatment. All tablet swallowing
needs to be controlled, individually, and
with the “nurse insistence” tailored to each
individual patient. This applies not only to
the initial phase of treatment,but also to the
continuation phase.
The old acronym can also be used as a
reminder to Health Staff supervising
treatment:
Directly Observed Tablet Swallowing…
The “spine-numbing” scene of a tin vat,
placed in the middle of a collective cell for
some twenty inmates, in a prison in Central
Asia, half filled with a collection of different
pills and blisters of all sorts of medicines,
dumped there literally by the inmates who
had received them in their continuation
phase of TB treatment, and “sorted out”and
taken (or not) as desired, without any con-
trol whatsoever, is hopefully a vision from
the past***
. However, inadequate supervision
of treatment, fostered by negligence, igno-
���������������������������������������������������������The“tin vat”incident is no“metaphor”:it describes
an actual situation seen by the author in 2000.
9
Emerging disciplines
rance,orfearofviolencefromsomepatients****
still does occur, and needs to be addressed
by providing more, better trained, and bet-
ter supervised staff for TB programmes*****
in
prisons.
Additional issues specific
to custodial settings
Many additional issues have already been
stated and detailed in previous publications.
Their relevance for the management of
“normal TB”treatment is even more signifi-
cant for all resistant forms of TB, including
MDR TB & XDR.
Management of adverse
effects of treatment
Correct management of adverse effects of
treatment, and, in fact, their identification
in the first place, has significant importance
in the prison setting. FLDs are known to
have effects that lead to self-interruption of
treatment by prisoners, if these patients are
not properly coached, counselled and assist-
ed by the medical and nursing staff. In the
case of MDR TB, as is well known, SLDs
have even greater adverse effects. Further-
more, because the duration of treatment is
24 months or more, such adverse effects can
and will become even more annoying to pa-
tients, increasing the importance of ensur-
ing sufficient support and expertise in their
management.
Erratic treatments are one of the main
causes of the selection of resistant strains of
������������������������������������������������������In some countries, prisoner “bosses” or “bullies”
will steal drugs given to patients, either forcefully,
if they have not yet been swallowed and are being
taken back to the cells, or by threatening patients
to conceal them from health staff, and deliver them
up…
������������������������������������������������������Two nurses in different contexts told the author
(only last year, 2009!) of how they had been threat-
ened by inmates, who did not want to take their Ri-
fampicin, so as to sell it or trade it off somewhere…
Again, for obvious reasons, these menaces were
impossible to “document” fully. Supervision was of
course tightened.
TB bacilli. It is therefore vital that health
staff working with TB patients in prisons be
sufficiently trained in all aspects of adverse
effect management, and be suitably firm in
their dealing with often difficult patients
who “want to have it their way”.
Contact management
and identification
A final issue arising in prisons, particularly
in overcrowded ones, is that of difficul-
ties in contact finding. Indeed, even where
staff and resources are sufficient, it can be
an overwhelming task to identify contacts
when a prisoner identified as having conta-
gious pulmonary TB has been living in an
impossibly overcrowded cell, and mingling
with dozens or even hundreds of other in-
mates. When staff and resources are lim-
ited, this effort is even more difficult.
Apart from the simple fact that there may
not be enough personnel to determine
which prisoners are at the highest risk for
contagion, there will again be additional
complications of the motives of the subjects,
similar to those factors that complicate an
initial diagnosis for TB. As soon as inmates
realize that there is an effort underway to
identify contacts of a diagnosed peer, they
may decide that there is something to be
gained from being identified as one (such
as a free trip to the hospital for investiga-
tions; better food in a health setting; being
excused from work; fewer security mea-
sures; etc.). Thus prisoners may present
themselves and (falsely) declare themselves
to be “contacts”, when, in fact, they are not.
These complications may be very difficult
to overcome, but health staff should at least
be aware of the different possibilities and
NTPs need to determine how factor them
into their overall evaluation of the TB situ-
ation in the prison.
All factors that have been mentioned here
need to be addressed by the relevant author-
ities. Administrative and structural consid-
erations, such as overcrowding, are a threat
to prison health and hence to public health.
The recruiting, training, supervision, and
adequate salaries of prison health staff need
to be addressed as well, and the resources
necessary to ensure them must be obtained.
There is no place for complacency in the
management of tuberculosis – all the more
so now that the much more deadly forms of
resistant TB are a growing menace to the
prison population, and community at large!
In Conclusion
Prisons have recently, that is in the past ten
years or so, finally been recognized as fo-
cal points in the fight against Tuberculosis.
Many (one would like to say “most”, but
such is not yet the case) major International
fora on Tuberculosis now have at least one
afternoon, or even a full day, on specific
prison issues regarding TB, MDR TB and
TB-HIV Co-infection.
It has been the objective in these few mod-
est pages, to underline once again the many
issues – some already well-understood and
others arising from the difficulties inherent
to the evolving disease itself – that need to
be known regarding prisoners and prisons
in the fight against TB and its dangerous,
continuous evolution to increasingly resis-
tant strains. Knowledge of the problems is
half the battle. Dr José Caminero stated at
the 2009 WMA Assembly Scientific Ses-
sion on MDR TB:
“If this is already true in the “outside world”,
it is even more so in the prison world, and in
10
Emerging disciplines
custodial settings in general. It is hoped that
pondering the few comments made here will be
useful to all dedicated medical staff working in
these difficult situations.”
Finally, as a final impetus for government
health and political authorities to dedicate
sufficient attention to the issues mentioned
here, it must be reiterated that tuberculosis
is not an isolated issue that concerns only
second-class outcasts (sic) who are locked
up behind walls, bars and fences. Epidemics
in prisons,including TB and the continuing
emergence of drug-resistant forms of the
disease, can and will spread to the outside
community. In addition, control of the TB
pandemic has been further complicated by
the co-existing HIV pandemic.
All stakeholders must remember that:
Good Prison Health is Good Public
Health !
References
Coninx R, Reyes H. Pitfalls of tuberculo-1.
sis programmes in prisons. BMJ. 1997 Nov
29;315(7120):1447-50.
Pearson M .Tuberculosis (TB) infection control:2.
a key strategy in the era of MDR-TB: presen-
tation at WMA scientific session. New Delhi;
2009.
Reyes H. Pitfalls of TB management in Prisons.3.
Int J Prison Health. 2007; 3(1): 43-67.
Guidelines for Control of Tuberculosis in Pris-4.
ons: TB/CTA*
and ICRC**
, 2009; Dara M;
Grezmska M; Kimerling M; Reyes H; Zagors-
kiy A.
Caminero, J: Approach to diagnosis of a patient5.
suspect of drug-resistant TB: training of trainers
workshop, Indian Medical Association – World
Medical Association. New Delhi, 12-14 Oct,
2009
Hernán Reyes, MD,
Medical coordinator, Health in
Detention, International Committee
of the Red Cross, Geneva (Switz)
e-mail: hreyes@icrc.org
* Tuberculosis Coalition for Technical Assistance;
** ����������������������������������������International Committee of the Red Cross
Elkhonon Goldberg
We are all familiar with the terms neurolo-
gy, psychiatry, neuroradiology, psychology,
etc., however a few decades ago a new term
appeared – “neuroscience.” Neuroscience
is an eclectic interdisciplinary field devot-
ed to the studies of the brain. Sometime
more recently, perhaps two decades ago or
so, yet another term was born – “cognitive
neuroscience.” Cognitive neuroscience is
devoted to the study of the brain mecha-
nisms of higher-order mental functions:
language, attention, memory, and even
decision-making. Even relatively recently,
these complex functions of the brain were
regarded as too intricate to allow rigorous
scientific investigation. They were the pur-
view of classic psychology whose adherents
not only did not know anything about the
brain but took pride in not wanting to
know. It was assumed that cognition could
be studied as a Platonic object without
bothering to relate it to the biological ma-
chinery that makes it run.
To a large extent it was a “sour grapes”
situation, since even if they desired the
information, there was not much in the
scientific research arsenal that would en-
able one to study the brain mechanisms
of the mind with any degree of precision
and rigor.To the extent that this was pos-
sible at all, our understanding of the rela-
tionship between the brain and cognition
was inferred from the observations of the
effects of various forms of brain damage
on behaviour.
All this began to change with the advent of
powerful neuroimaging tools. It has been
said that the advent of these methodologies
were to neuroscience what the invention of
telescope had been to astronomy, or the in-
vention of the microscope to biology. Neu-
roimaging completely revolutionized the
ways the brain mechanisms of higher-order
cognition are studied.
We distinguish between two broad classes
of technologies: structural neuroimaging
and functional neuroimaging. Structural
neuroimaging includes Computerized
Axial Tomography of the brain (CT) and,
particularly, Magnetic Resonance Imaging
(MRI) of the brain. Whereas in clinical
practice a neuroradiologist usually “eye-
balls” the images generated by these tech-
nologies, in research, CT and MRI data
are subject to precise quantitative measure-
ments, called quantitative morphometry,
which make much more precise character-
ization of various features of normal and
abnormal brain possible. More recently,
various methods, Diffusion Tensor Imag-
ing (DTI) among them, have been devel-
oped to examine pathway architecture in
the brain.Owing to these various neuroim-
aging methods, we now know that gender
differences exist in normal brains. The two
hemispheres are more symmetric in fe-
Neuroimaging and the birth of
cognitive neuroscience
11
Emerging disciplines
males than in the males; certain aspects of
the corpus callosum are thicker in females
and certain long intrahemispheric path-
ways are thicker in males. We know that
the hippocampi may exhibit size reduction
in people likely to develop Alzheimer’s
disease long before any clinical symptoms
emerge. We know that the brains of people
who eventually develop schizophrenia ex-
hibit abnormal neurodevelopmental couse
years before the first clinical symptoms
emerge. We know that chronic anxiety is
associated with hippocampal atrophy and
Post-Traumatic Stress Disorder (PTSD) is
often linked to a reduction in size of the
ventromedial prefrontal cortex. We know
that the effects of experience-driven neu-
roplasticity may result in an actual size
increase of the brain regions involved in
particularly vigorous cognitive activities.
These are but a few examples of the find-
ings obtained with the methods of quanti-
tative morphometry and tractometry.
Functional neuroimaging includes Positron
Emission Tomography (PET),Single Pho-
ton Emission Computerized Tomography
(SPECT), Near-Infrared Optical Imag-
ing, and, particularly, functional Magnetic
Resonance Imaging (fMRI). These tech-
nologies are based on different underlying
physical principles and their discussion is
outside the scope of this review, but they
all permit direct examination of activity
patterns in a living brain. While character-
izing regional patterns of neural activity
is the ultimate goal pursued by functional
neuroimaging, this is accomplished, as a
rule, through various “proxy measures”pre-
sumed to be highly correlated with neural
activity levels. Blood oxygen levels in fMRI
or glucose metabolism levels in PET are
examples of such proxy measures. In prin-
ciple, functional neuroimaging can be used
both in a resting state and during various
mental activities.
As mentioned earlier, functional neu-
roimaging has revolutionized both cogni-
tive and clinical neuroscience. In clinical
neuroscience functional neuroimaging
was particularly instrumental in helping
characterize disorders devoid of clear-cut
macroscopic focal brain lesions, e.g. various
neuropsychiatric and neurodevelopmental
disorders. Studies using PET and SPECT
helped clarify the mechanisms of various
such disorders. Aberrant activity in the
striatum (putamen and caudate nuclei) in
Obsessive-Compulsive Disorder (OCD)
and Tourette’s syndrome; “hypofrontal-
ity” in schizophrenia and certain affective
disorders; and exceptional frontal-lobe
vulnerability in closed Traumatic Brain In-
jury (TBI) are but a few examples of such
findings.
For a variety of technical and conceptual
reasons, cognitive neuroscience has fo-
cused predominantly on activation para-
digms using fMRI, where brain scanning
takes place while the subject is engaged
in various cognitive tasks. An elaborate
research methodology has developed to
support such studies, sometimes referred
to as “subtraction methodology.” The spe-
cific findings acquired with this method-
ology are too numerous to list here. These
findings have permitted direct test and
validation of many of the assumptions
about functional organization of the brain
inferred in the decades past from the le-
sion studies, and have served to infuse our
understanding of the brain mechanisms of
complex cognition with an unprecedented
degree of neuroanatomical precision.
For the first time in the history of brain
research, it became possible to directly ex-
amine the temporal dynamics of complex
mental processes as they unfold in time in
the course of learning. It became possible to
examine how particular brain regions work
in concert as interactive neural networks un-
derlying complex cognition and how these
network interactions may become aberrant
in various disorders.Furthermore,it became
possible to study various higher-order func-
tions often referred to as “metacognitive,”
such as complex decision making, social
cognition, and the mechanisms of insight
into other people’s minds (“mentalizing”),
both in normal individuals and in various
poorly understood disorders such as au-
tism.
This, in turn, expanded the frontiers of
cognitive neuroscience into the areas of
interface with other disciplines, such as
economics, politics, social interactions, and
ethics. As a result, entirely new areas of in-
quiry have coalesced on these boundaries
between traditional disciplines, and we hear
about “neuroeconomics”, “neuromarketing”,
“neurolaw”and other “neuro’s”unimaginable
even a few decades ago,which are concerned
with the brain mechanisms underlying cog-
nition and behaviour in these diverse arenas
of human endeavour.
Different eras are characterized by differ-
ent directions of thrust of scientific inquiry.
Just as the first half of the twentieth cen-
tury was the era of physics and the second
half of the twentieth century was the era
of biology, the foreseeable beginning of the
twenty-first century is shaping up as the
era of neuroscience in all its multiple and
constantly expanding applications. If, as it
has been said, the brain is science’s “last
frontier”, then we are finally on the verge
of piercing and eventually conquering this
frontier.
Elkhonon Goldberg, Ph.D., ABPP
New York University School of Medicine
New York, NY, USA
e-mail:egneurocog@aol.com
12
Medical Ethics, Human Rights and Socio-medical affairs
The draft of the WHO Global Strategy to
Reduce Harmful Use of Alcohol (GAPA)
is now available at the WHO website
(document EB126/13 in English, Spanish,
French, Arabic, Russian & Chinese): www.
who.int/substance_abuse/activities/global-
strategy/en/index.html, and here: apps.who.
int/gb/e/e_eb126.html
The document consists of three parts: The
report by the secretariat, including a draft
resolution for consideration by the WHO
Executive Board, the Draft Strategy itself,
and a two page summary of the evidence for
the effectiveness and cost-effectiveness of
the proposed interventions. In addition, the
document contains a bibliography on evi-
dence on harmful use of alcohol, published
separately on the WHO Substance Abuse
website.
Although some of the sections of the draft
strategy should be improved and strength-
ened,we believe that the Strategy effectively
addresses issues that will be critical in public
health efforts to reduce the toll of alcohol
throughout the world. The attached GAPA
response provides general and specific com-
ments regarding both the strengths and
weaknesses of the existing draft.
The draft Strategy will be submitted to
WHO Executive Board January session for
discussion and approval. The international
drinks industries and their social aspect or-
ganisations have launched several initiatives
to influence the Strategy process. Those
initiatives include industry front-group
International Center for Alcohol Policy
(ICAP)’s recent publication of “Working
Together to Reduce Harmful Drinking”,
an attempt to strengthen industry’s role in
the development and implementation of a
Global Strategy.
GAPA expects that some Member States
might attempt to weaken the scope and
content of the Strategy, and may even block
its adoption. The Executive Board meeting
begins on January 18 in Geneva and NOW
is the time for concerned GAPA partners
and other nongovernmental organisations
to act at country-level in support of the
adoption of the Strategy. May we also sug-
gest that you spread this action alert to oth-
ers in your network.
ACT NOW
We strongly urge you to contact your Health
Minister (or health ministry) now in sup-
port of the Global Strategy. Please ask for
a meeting with the Minister, or members of
the delegation that will attend the WHO
Executive Board meeting. We encourage
you to raise the following points in your
contacts with your Minister and/or EB del-
egation, depending on the situation in your
country:
1. Express your support for the Draft
Global Strategy as a key starting point
in addressing the global threat to health
represented by the harmful use of alco-
hol;
2. Make your strong recommendation that
the Strategy should be adopted in its
current version at the minimum, and
possibly with amendments strengthen-
ing it in the way outlined in the attached
GAPA response document;
3. Assert that the harmful use of alcohol
on the global level is a long-overdue re-
sponsibility of Member States and the
WHO;
4. Emphasize that the involvement of non-
governmental organisations is essential
in policy development and implementa-
tion and that NGOs are willing to col-
laborate fully with WHO and Member
States in this process;
5. Address the need to limit economic op-
erators’ involvement in the Strategy and
to insure that policies and programs at
all levels are developed by public health
interests independent of commercial
conflicts;
6. Recognize that additional resources will
be required at all levels to implement
effective national, regional, and global
strategies to reduce the harmful use of
alcohol, and countries in the developed
world should make the necessary funds
available to WHO;
7. Convey the information that represen-
tatives of the Global Alcohol Policy
Alliance (GAPA) will be attending the
Executive Board meeting and look for-
ward to conferring with country delega-
tions at that time.Please encourage your
Health Minister and delegates to get a
global NGO perspective during the EB
session.
GAPA contacts:
George Hacker: ghacker@cspinet.org
Øystein Bakke: oystein.bakke@forut.no
Action alert
Country-levelsupportneedednowfortheglobal
strategy to reduce the harmful useofalcohol
13
Medical Ethics, Human Rights and Socio-medical affairs
In January 2010, the Executive Board of the
World Health Organization will consider a
Draft Global Strategy to Reduce the Harmful
Use of Alcohol.This proposal comes none too
soon, considering the enormous impact that
alcohol has on global public health.The exces-
sive use of alcohol is the third-leading risk fac-
tor for premature deaths and disabilities in the
world,accounting for some 2.5 million deaths
in 2004.That equates to 3.8% of all deaths and
4.5% of the global burden of disease as mea-
sured in disability-adjusted life years lost.
TheGlobalAlcoholPolicyAlliance(GAPA)*
strongly supports the December 3, 2009
Draft Global Strategy and recommends it
to the Executive Board and Member States
for approval. Although some of its sections
should be improved and strengthened (as
indicated below), we believe that the Strat-
egy effectively addresses issues that will be
critical in public health efforts to reduce the
toll of alcohol throughout the world.In par-
ticular, we note the following essential com-
ponent strengths of the Strategy:
Its foundation rests on strong, evidence-•
based policies that can provide guidance
for Member States;
It recommends, in accordance with the•
evidence base, essential policy interven-
tions regarding price, availability, drink-
driving countermeasures and marketing;
It addresses the need for resource devel-•
opment and issue prioritization in imple-
menting alcohol prevention strategies at
the global and national levels;
* The Global Alcohol Policy Alliance (GAPA) is a world-
wide coalition of NGOs, medical professionals, and re-
searchers who work to prevent alcohol problems and reduce
their toll on society. GAPA, which includes representation
from all inhabited continents, was formed in 2003 and is
headquartered in London, England.
It recognizes that the involvement of civil•
society is essential in creating the political
will to address alcohol issues and imple-
ment national and global prevention
strategies;
It acknowledges the responsibility for•
health-sector leadership within multisec-
toral collaboration on efforts to combat
alcohol problems at all levels;
It suggests a special focus on protecting•
the young, non-drinkers, and populations
at risk from harmful use of alcohol, such
as women, indigenous peoples and other
low-income or minority groups;
It anticipates the involvement of all par-•
ties, including “economic operators”,
in implementing strategies at all levels,
while pointing to reasonable distinctions
in their roles, depending on commercial
interests involved.
GAPA believes that the Strategy’s Aims
and Objectives, Guiding Principles, and
Policy Options and Interventions are clear,
balanced, and comprehensive. They express
a vision that can begin to address global
harm from alcohol.
GAPA Concerns
Alcohol Marketing Issues
GAPA is disappointed by the weakness of the
policy discussion concerning the marketing of
alcoholic beverages. In particular, we note that
the suggested policy interventions include co-
regulation and industry self-regulation as “ap-
propriate”parts of the strategy.Neither of these
has an evidence base of effectiveness – in fact,
several studies of self-regulation have found it
ineffective.Voluntary codes of good marketing
practice are routinely violated, nearly impossi-
ble to enforce in a timely manner,and condone
much of the advertising and promotion, such
as sports sponsorship and trans-national mar-
keting messages, about which Member States
have expressed concern.
GAPA believes that self-regulation and/or
co-regulation are hopelessly inadequate sub-
stitutes for strong governmental regulation
of alcohol marketing, and that the Strategy
should reflect that reality. The strategy also
weakens the specific recommendations in
this section by removing the word “ban”and
leaving “restrict”as the only option.The evi-
dence base is strongest in support of bans on
marketing, and various forms of marketing
are already banned in numerous Member
States. Therefore, bans should be explicitly
on the table as options for Member States.
Appropriate Roles for Different Parties
The document contains several references
to the need for “partnerships” and GAPA
welcomes the call for various governmental
and non-governmental entities to partner
with WHO to address these problems. The
document also addresses the appropriate
roles of different parties concerned about
alcohol policies. GAPA believes that the
Draft Global Strategy should be improved
by explicitly addressing the “appropriate”
role of “economic operators” in the process
of developing and implementing evidence-
based, preventionoriented policies to reduce
the harmful use of alcohol.
To avoid conflicts of interest, the strategy
should clearly state that policies and pro-
grammes to reduce alcohol-related harm
need to be developed independent of com-
mercial interests. Economic operators
should avail themselves of opportunities to
be in dialogue with WHO and other gov-
ernmental bodies regarding their contribu-
tions,in their roles as alcohol producers,dis-
tributors, sellers, promoters to the reduction
of alcohol problems. Such contributions to
the implementation of alcohol strategies at
all levels should be consistent with a duty to
avoid interfering with public health objec-
tives and public health policy.
Response of the Global Alcohol Policy
Alliance to WHO’s
Draft Global Strategy to the Reduce the Harmful Use of Alcohol
December 2009
14
Regional and NMA news
When the Monet/Schumann inspired
initiatives extended the early post-second
World War agreements in some States
(such as the Coal and Steel Treaty, Paris
1951) to build structures which would
militate against any further European
conflicts culminated in the Treaty of
Rome (1957) and the establishment of the
European Economic Community (EEC),
the medical profession reacted by forming
a “Comité Permanente des Médecins de la
CEE” (CPME or CP). This year CPME
celebrates its 50th
anniversary.
The various Treaties signed by Member
States had created a political economic
community with legislative powers on de-
fined topics (which have increased as the
Community has expanded and subsequent
Treaties and changed new or amended
legislation have been adopted). This ar-
ticle provides some information on the
background to the CPME’s foundation,
its work and some of the problems it faced
in the following years.
The following short glossary of terms used in
this article will assist those not familiar with
the EEC and associated institutions.
European Economic Community (EEC)
later known as the European Union (EU)
The Council of Ministers (The Council) con-
sists of Ministers from Member States who
adopt legislation, Regulations, Directives and
Decisions etc.
Regulation: European Legislation which has
to be directly incorporated into national law.
Directive: European legislation, the effect of
which has to be incorporated in national law.
Decision: Specific measures which are binding
on those to whom they are addressed.
European Commission is effectively the Ex-
ecutive of the EU, comprising representatives of
the Member States appointed as Commission-
ers with specific responsibilities for differing
sectors (Directorates General (DG’s) within
the European Commission. It is responsible for
proposing legislation and guarding the imple-
mentation of the provisions of the Treaties.
After 50 years of impressive activity the
CPME (referred to in its early years as the
“CP”, an acronym used in the early part
of this article), has good reason to look
back and reflect on the wisdom and work
of those who, in the light of the Treaty of
Rome (Tof R) 1957, recognised the need
were responsible for its foundation, and to
those individuals who over the years have
made huge contributions to the work of the
CP. The tasks which CP has undertaken
on behalf of the medical profession (and
the citizens) of the European Union have
contributed enormously to the realisation
of the principles and evolving ambitions of
the European Community which, amongst
its many other objectives, were to meet the
social,healthcare and safety needs of its citi-
zens and the facilitation of free movement
of workers,including the medical,paramed-
ical and pharmaceutical professions.
Foundation
The “Comité Permanent des Médecins de la
C.E.E.” (Standing Committee of Doctors
of the EEC, ultimately changed to Standing
Committee of European Doctors), was found-
ed in Amsterdam in 1959 by the original Six
National Medical Associations (NMAs) of
the Member States of the European Eco-
nomic Community, Belgium, France, Ger-
many, Netherlands, Italy and Luxembourg,
all of them members of the World Medical
Association (WMA).
The founding NMAs’ activities were es-
sentially to defend the principles on which
medical practice should be based, both in
the interests of healthcare of all the citi-
zens of Six member states of the European
Community which also meant engagement
as “the patient’s advocate” (a role often re-
ferred to in CP debates), in addition to
safeguarding the standards of the medical
profession in sustaining its role and func-
tions in the European Community.
The CP Statutes (1960) initially provided
for each NMA to undertake the Presidency
and Secretariat in rotation annually. This
was soon changed to 2 then to 3 years, and
is currently two years (2010).
From the earliest meetings of the CP, in ad-
dition to the formal members, a represen-
tative of the Austrian Medical Association
and a representative of the World Medi-
cal Association were present as Observers.
They were joined as observers by the British
Medical Association in 1961 and soon after
by the NMAs of those countries with ap-
plications to join the EEC including Den-
mark, Ireland and Norway. Norway with-
drew its application when the referendum
rejected membership at the first community
enlargement when Denmark, Ireland and
the UK joined the EEC (1972). Thereafter
observer status was offered to those NMAs
Reflections on the Standing Committee
of European Doctors’ (CPME)
Fiftieth Anniversary 1959-2009
Alan Rowe
15
Regional and NMA news
whose countries were seeking membership
of the EC.
The structure, organisation and activities of
the CP over the years has naturally been in-
fluenced not only by major events and EEC
legislation in the evolving European Com-
munity and its society,but also increasingly by
global events and developments,including ad-
vances in scientific and technical knowledge,
political, social and demographic change, the
communication revolution, natural disasters
and new challenges in disease control.
Language and Interpretation
The CP, comprising representatives from
various member states speaking different
languages, had a particular need for clear
understanding of the draft legislation they
were dealing with. From the beginning a
team of interpreters were necessary. Both
simultaneous translation and on occasions
consecutive translation were used, although
the latter was abandoned as it was so time
consuming. The expertise of the interpreta-
tion team with their particular knowledge
both of medical technical language and that
associated with legal and community affairs
(many also worked in the European institu-
tions) made a huge contribution to the work
of the committee. Now the CPME works
mainly in English.
CP – The early period
In one sense, the first period of CP activity
was largely focused on problems associated
with Freedom of Movement, Professional
Recognition and Practice in the European
Economic Community (EEC). Essentially
this period began in 1959 (The EEC officials
responsible for the drafting of legal Direc-
tives providing for the freedom of movement
of professionals referred to in article 57 (also
48.4 and 60) of the 1957Treaty of Rome had
begun their enquiries in 1958).
The full implications at this time of the
most important article 57 (see box ) and
the problems with which the CP were faced
need to be put into context.
Article 57 ( Treaty of Rome)
1. In order to facilitate access to and engage-
ment in non-wage-earning activities, the
Council shall issue directives for the mutual
recognition of diplomas,certificates and other
evidence of qualifications. The Council shall
so act, on a proposal of the Commission and
after the Assembly has been consulted,during
the first stage unanimously and subsequently
by qualified majority vote.
2. With the same object, the Council, on a
proposal of the Commission and after con-
sulting the Assembly. shall before the tran-
sitional period ends .issue directives for the
co-ordination of the legislation, regulations
and administrative rules of Member States as
regards persons taking up non-wage-earning
activities. Voting must be unanimous on the
following matters: i.e. those which are the
subject of legislation in at least one Member
State; those concerned with the protection of
savings, in particular the granting of credit
and the carrying on of the banking profes-
sion; and the conditions governing the car-
rying on of the medical, para-medical and
pharmaceutical professions in the various
Member States. In all other cases, the Coun-
cil shall act unanimously during the first stage
and subsequently by qualified majority vote.
3. In the case of the medical,para-medical and
pharmaceutical professions, the progressive
removal of restrictions shall be dependent
upon the conditions for exercising them
being co-ordinated in the various Member
States
In the late 1950’s there were a few limited
bilateral agreements between individual
countries for mutual recognition of medi-
cal degrees and qualifications (somewhat
later, the Nordic Agreement on Cultural
Co-operation (1971) laid the grounds for
mutual recognition in the Scandinavian
countries, fulfilled in 1975. The decision
in article 57 of the TofR therefore raised
considerable problems. Hence, in part, the
special provisions for mutual recognition of
qualifications and coordinating provisions
for health professionals’ activities set out in
article 57. These required unanimous deci-
sion by the Council of Ministers initially in
adopting proposed legislation and decisions
­thereafter by qualified majority; also that
progressive abolition of restrictions for the
medical, paramedical and pharmaceutical
professions be dependant upon coordina-
tion by Member States.
Clearly the Commission needed some form
of Medical Advisory Body providing the
voice of the medical profession and other
health professions in the process of produc-
ing draft proposals for Directives. (In fact
it did not officially establish one until the
1975 Doctors Directives were finally ad-
opted, when a Council Decision set up an
Advisory Committee on Medical Training
(ACMT)in the Commission).
The NMA’s, however, foresaw the need for
the profession‘s views to be coordinated and
promoted to the EEC authorities and thus
the CPME was founded in 1959.The Com-
mission accepted discussions/communica-
tions with the CP, recognising the value of
information and opinions from such a body
and its importance in representing the physi-
cians in Member States. (In this connection it
is of interest to note that in the original Stat-
utes,article 1 referring to the national delega-
tions from each country determined represen-
tation of member associations as “6 delegates
and 6 alternates are to be nominated by the
NMA or national professional organisation
in such a manner that the delegation is repre-
sentative of the medical body of its country”).
Other European bodies representing specific
areas of medical practice, AEMH (hospital
doctors, FEMS (Salaried doctors),UEMO
(general practitioners) PWG (Junior doc-
tors) became CP observers and appointed
liaison officers to the CP.
By 1972/3 the relevant time the EEC Com-
missioner, Professor Ralf Dahrendorf (later
Lord Dahrendorf), recognised that more
rapid progress needed to be made and that
there were still basic problems to be solved.
He therefore convened the famous “Dah-
rendorf Hearing” (October 1973) in which
parties from the Old Six and the three new
acceding countries were included. Other
16
Regional and NMA news
interested parties included the Universities,
the practicing Medical Profession, other
health professions, the EEC institutions,
Consumer organisations, National govern-
ments and other bodies. From this Hear-
ing emerged the concept of an Advisory
Committee on Medical Training (ACMT).
Thereafter, progress was more rapid.
However, only in 1975 (after 16 years of
discussion of drafts and redraft of propos-
als from the Commission!) was there suf-
ficient agreement amongst Member States
for Directives to be adopted by the Council
of Ministers as the basis for mutual recog-
nition of both basic and specialist medical
degrees and diplomas, as well as coordinat-
ing provisions for those wishing to migrate
within the European Community.
These directives (75/363/EC & 75/364/
EC) covered mutual recognition of basic
medical qualifications and a number of
specified specialties, as well as the necessary
coordinating provisions.
Although there had been CP representations
concerning specific training for General Prac-
tice in the early 60’s,it was not until 1986,af-
ter nearly 20 years of continual consideration,
discussion and representations, that an initial
Directive (86/457/EEC) was adopted. Even
so recognition for the purposes of practice as
a general practitioner in a national social se-
curity system was only to be complied with by
1995.The directive also provided for a report
by the Commission on developments and
experience in the intervening years on which
the Council should act to extend the training
to all general practitioners.
Some of the proposals made by the CP
and other bodies on the various draft pro-
posals were not included in the final texts
adopted by the Council in 1975. Notably,
the idea of an obligatory “period of adap-
tation” in the host country before a mi-
grating physician would be free to practice
independently in medical practice. Such a
“period of adaptation” was strongly sup-
ported by the CP, a view also supported
by both the European Parliament and the
Economic and Social Committee. (This
view has been subsequently raised again
in various EEC institutions from time to
time) It would be many years before the
Commission incorporated such an idea
in the General Service Directive covering
those professions for whom no specific
Directive had been adopted.
Directives for Nurses, Midwives, Pharma-
cists and Veterinary Surgeons were soon
adopted in the years following 1975. All of
these were subject to coordinating directives
for these health professionals on more than
one occasion. At all stages of the processes
leading to the adoption of these directives,
their amendments and co-ordination, the
CP’s work included scrupulous monitoring
of the texts and their implications and dis-
cussions with the European Commission.
The “doctors’ directives” can be regarded as
the foundation Directives for freedom of
movement of health professionals in the Eu-
ropean Union.They continue to be discussed
and revised, dealing with changes in the spe-
cialties, clarification and expansion of issues
in the ‘75 Directives (such as occasional non-
established provision of services,cross board-
er medical practice, recognition of certain
specialties) and incorporated in coordinating
directives. They will no doubt continue to
develop from time to time, reflecting other
major changes and developments.
In this connection it is significant to
note that in 1976, the concerns of the le-
gal profession (who had no directives at
that time) were discussed at a conference
celebrating the 10th anniversary of the
“Cahiers de Droit Européene” entitled
“The free movement of lawyers and doc-
tors in the European Economic Com-
munity”, The conference considered the
lawyers concerns about possible directives
for their own profession) in the light of
the approach adopted in the doctors’ di-
rectives. At this conference many of the
problems of the 1975 doctors’ directives
were reflected in the concerns of the law-
yers. (“Cahiers de Droit Européen” 1976,
Supplément)
CP and Other European Directives
While questions arising from the 1975 doc-
tors directives added considerably to the work
of the Standing Committee,it must be recog-
nised that in addition to the work associated
with the medical directives (especially the role
of Occupational Health which profession-
ally had already been involved in the context
of the 1951 Coal and Steel and later in the
1957 Euratom Treaties), and work on Social
Security, the CP increasingly had to monitor
and act on many non-medical directives ad-
opted by the EEC but having implications
for medical practice both in healthcare and
other fields than medicine, Examples in-
clude the Directive on “Liability for Defective
Products”,a draft Directive on “Liability for
Defective Services” which – eventually aban-
doned – re-emerged again some years later,
and the so called “Advertising Directive” on
pharmaceutical products,notably article 3.
CPME The Middle period –
Maastrecht, Amsterdam
The second period of the CPME’s activity,
starting in the early 8o’s, was influenced by
a number of factors. In one sense, the most
important event relating to health in the EU
in this period was the formal reference to
Public Health in Title X, article 185 of the
Treaty of Maastricht (1993) (the first time
that actions in the health field had been
mentioned in the European Treaties!) – and
the inclusion of an article in Title XI on
Consumer Protection.The political changes
in Europe in the early 90’s and the rather
later enlargements of the membership of the
European Community were also to impact
on the CP, its organisation and member-
ship. In this period the CP had continued
to enlarge its membership,first from 9 to 12
and then 15, plus many observers, most of
whom later became members.
17
Regional and NMA news
Although already dealing with an enlarged
agenda in the early 80’s and 90’s subsequent
events, notably the establishment of DG
SANCO (General Directorate, Health and
Consumer Affairs) in the late 90’s, increased
the workload on the CP in responding to EU
policies and activities even more. In addition
by the late 1970’s and early 80’s the CP had
already extended its activities to include is-
sues arising from organisations outside the
EU,including the Council of Europe,WHO,
the GATT negotiations etc. In a globalising
world, towards the end of the 20th century
and beyond, the incidence of diseases such as
AIDS in the 80’s,SARS in 2003 and MRSA,
as well as rapidly increasing scientific devel-
opments such as those arising from genetic
research and the genome project, have raised
more clinical and ethical problems.All of this
has been in addition to the expanding work
of the EU in the field of Information Tech-
nology and more recently on E-health,which
requires considerable CPME engagement.
A Brussels Office
For over 30 years the CP from time to time
had heated debates about establishing an of-
fice in Brussels or Strassburg. The increased
workload eventually led to work being start-
ed to review and consolidate the CPME’s
position in 1992. It developed by way of es-
tablishing a Brussels office and staff, a Board
and an Executive Committee and ultimately
an employed Secretary General.
These major decisions approved in 2002,
reflected the increasing achievement of the
CPME over the preceding decades of its
aim to respond to and influence develop-
ments in the European Community.
Committees
In order to carry out its work the CP had,
from its earliest days established commit-
tees or working groups. In the first four
decades of its existence these reflected the
fundamental planks of medical practice, its
engagement with society, as well as various
more specialised areas. For many years the
list was extensive comprising the following:
Professional
Training
Occupational
Health
Hospital Doctors Paramedical
Professions*
Social Security Doctors the
Pharmaceutical
Industry
Salaried Doctors Juristes**
Medical Ethics General Practice
While the functions of most of these com-
mittees are clear, and can be related to the
structures mentioned later which have re-
placed them, the following notes indicate
the functions and value of two committees
which have disappeared.
* The Paramedical Committee (also no lon-
ger existing) reflected the provisions of Ar-
ticle 57 of the Treaty of Rome referring to
the medical, paramedical and pharmaceuti-
cal professions”. The CP by the late 60’s had
established a committee on the Paramedical
Professions, in whose role and education the
medical profession had considerable interest.
At a very early stage in the late 70’s however,
one incident is worth recording as it reflect
a widely held attitude at that time – an atti-
tude which has radically changed since then.
It should be noted that for at least two thirds
of the last century amongst the old Six and
a number of other countries of continental
Europe, doctors played a major role in con-
trolling the schools of nursing.The emphasis
was on nurses and others as “paramedicals”,
who were to assist and be responsible to doc-
tors. On one occasion, when the committee
was discussing the paramedical professions,
it was pointed out that “just as the organisa-
tion and functions of the medical profession
were evolving, so also were the roles of the
paramedical professionals and this was natu-
rally to be expected. It was further pointed
out that the first two Chairs of Nursing had
just been established in European Universi-
ties and that no doubt this trend would ex-
tend and also be reflected in other paramedi-
cal fields. Despite support from one of the
lawyers this produced an explosion from the
Chairman who castigated both speakers and
commented: “No-one will interfere with the
acts reserved as fields of activity for special-
ists.”How things have changed!
** The Juristes Committee (legal assistance is
now sought when it is specifically required)
was of particular importance, especially in
the consideration of the many initial drafts
of the Doctors Directives in the late 60’s, the
70’s and early 80’s. At the time of the CP’s
foundation, all delegations in the CP were
accompanied by their lawyers.This was large-
ly a consequence of the Treaty of Rome, the
consequential legislation and its implications
for National Law in Member States and for
medicine. It’s work expanded with the de-
velopment of legislation from other sectors
of the Commission which had implications
for medicine and as advances in technol-
ogy (such as data storage), medical research,
healthcare services – their provision and
safety, took place. This committee’s advice
on the Doctors’ Directives was invaluable,
both in the drafting period and also with the
problems continually arising once they had
been adopted,or as various proposed amend-
ing directives appeared. This also applied to
their assistance on wide ranging directives
with implications for medicine and health-
care. Unsurprisingly, the Juristes also greatly
assisted in the formulation of Charters and
Declarations relating to the work of the com-
mittees and,of course,the drafting of the CP
Statutes and their various revisions.
Today, following the review referred to
above, a smaller number of committees, re-
flecting the broad areas of engagement, are
currently as follows:
Medical Training, continuing profession-•
al development and quality improvement
Ethics and professional codes•
Organisation of health care, social secu-•
rity and health economics
Public health, prevention and environ-•
ment
18
Regional and NMA news
2000 and beyond*
In a European Union now enlarged to 27
Member States, the CPME today has a
Brussels office, is registered as an Interna-
tional Association under Belgian Law and
has a membership of 27 National Medical
Associations,2 Associated Members,2 Ob-
servers and 9 Associated bodies. One look
at its website today (www.cpme.eu) shows
its continuing engagement with other Eu-
ropean Medical bodies, its policies**
, state-
ments and decisions; its engagement with
and representations to the major Institu-
tions of the European Union; participation
with European non-EU bodies both medi-
cal and non-medical,and its inclusion in the
European Commission’s consultations. All
of this recognises the importance attached
to its opinions by the relevant EU institu-
tions, demonstrates the significance of the
CPME’s work, its growth in stature and its
influence over the past fifty years.
Over the past 50 years there were occasions
when there were substantial differences of
opinion both between national delegations
and even within delegations, and there were
frank and often forceful expression of views
in the early and middle phases of CP’s exis-
* A More detailed account will appear in a history of the
CPME in preparation.
** The Policies of the CPME can be found at www.cpme.
eu/policy/php
tence.However,there were few occasions on
which unanimous or substantial consensus
in the debates were not eventually reached.
Differing legal systems and social security
provisions (both affecting medical practice)
contributed substantially to the problems of
ensuring that adequate discussion recogn-
ised the difficulties and the problems they
might pose in particular member states.
Healthcare provision in certain individual
member states had not, for financial, politi-
cal, administrative or other reasons, devel-
oped to the general standards of the major-
ity of member states. Cultural, linguistic,
national and even philosophical factors all
played a part in achieving agreed positions.
To achieve this called for understanding by
all parties of the real problems of certain
NMAs., These were sometimes medico-
political, sometimes cultural, which led to
some delegations’difficulties in understand-
ing the difference between influencing pro-
posed supranational legislation, as opposed
to national legislation or regulation relating
to healthcare and professional practice.
National Delegations sometimes approach
discussions with a strictly national posi-
tion based on their own experience. This
has called for considerable diplomacy in
explaining overall trends within the Euro-
pean Community. For some countries this
was more difficult than for others. Never-
theless eventually decisions had to be taken,
sometimes involving compromise – a pro-
cess which could take a considerable time in
order to achieve a form of words acceptable
to the majority. On occasions this might
require agreement that representation be
made by the CP directly to appropriate in-
stitutions on specific problems which some
aspects of draft proposals for Community
legislation would pose for national authori-
ties and NMAs in certain member states.
As the Community has substantially en-
larged in the last two phases of its develop-
ment and bearing in mind the increasingly
globalising world, the need for diplomacy,
readiness to appreciate and understand
the contributions, the manner and back-
ground against which such expressions of
opinion are made from other EU coun-
tries, has become even more important.
Unfortunately there is currently evidence of
a failure by some NMAs to recognise the
importance of full participation by all the
EU national medical associations (includ-
ing respect for these qualities) by the rep-
resentative NMA’s in influencing proposed
EU legislation and other actions affecting
the medical profession through the open
dialogue and professional positions reached
by the CPME. Such attitudes disregard
some of the fundamental aims and objec-
tives of the EU set out in its Treaties.
Dr. Alan Rowe, Co-Editor WMJ
e-mail: member@rowe110.fsnet.co.uk
EPF was founded in 2003 and has become
the ‘umbrella’ of patient organisations in
Europe. Our foremost aim is to be a united
and influential patients’voice in Europe and
to promote the patients’ perspective in EU
healthcare debates. We try to reflect the pa-
tients’, their carers’ and families’ unique and
direct experience and expertise in healthcare
through member organisations’ links with
representative national, regional and local
patient organisations in all 27 EU Member
States. Currently we represent 39 patient
organisations, which are chronic disease-
specific patient organisations working at
EU level and national platforms of patient
organisations.
The European Patients’ Forum focuses on
genuine patient involvement in EU health
policy and projects, as well as exchange of
good practice and peer support among and
within patient organisations at European
level. We try to promote a holistic, patient-
centred, non-discriminatory interpretation
The European Patients’ Forum (EPF)
Nicola Bedlington
19
Regional and NMA news
of healthcare, to include prevention and the
social, economic, environmental, cultural
and psychological aspects of health.
Our vision is high quality, patient-centred,
equitable healthcare for all patients across
the European Union. Our activities and ac-
tions are driven by five fundamental goals:
Equal access for all patients to best qual-•
ity information and healthcare;
Patient involvement in health-related•
policymaking and assessments, programs
and projects;
Patients’perspective to be included in de-•
cisions on health economics and health
efficacy;
Sustainable and inclusive patient organi-•
sations to effectively represent patients
and their interests;
Patient unity as part of a patient move-•
ment at European level.
In the light of these goals,the European Pa-
tient Forum produces targeted communica-
tion tools, engages in evidence-based sur-
veys linked to patient-centred healthcare,
develops qualitative and credible evidence
on patients’ experience, participates con-
structively in major external health events
and works in cooperation with appropriate
research networks and other NGOs in the
health care sector to enhance grass-roots
evidence based argumentation for campaign
and policy work.
We organise annual regional advocacy
seminars in different parts of Europe. Our
next one will take place in Sofia, Bulgaria
and will involve 50 patient leaders from that
region. We also hold an annual conference
to help to profile our core policy priorities.
In 2007, the EPF Conference focused on
“Empowerment, Information, Sustainabil-
ity“, and in 2008 on “Health Literacy” .
We respond on a regular basis to consulta-
tions by the European Commission on leg-
islative proposals such as the Pharmaceuti-
cal package on information to patients, fake
medicines and pharmacovigilance.
We work closely with the European Parlia-
ment, the European Council, the Member
States and the European Commission to an-
chor a patient-centred health care policy in a
long-term European strategy.In this context,
we do not limit our campaign work to EU
institutions, but also try to build relation-
ships with other important institutions such
as the World Health Organization – Europe
Region, Council of Europe and the OECD.
In 2008, we launched “The Patients’ Mani-
festo – 150 million reasons to act” that calls
for vital new measures in three fundamental
areas to improve the quality of health care
delivered across the European Union:
Equal and timely access to safe, effective•
diagnosis, treatments and support;
Better information and resources allow-•
ing patients to be partners in determining
their care;
Provision for a patient’s voice to be heard•
in Brussels and throughout the European
Union.
The Manifesto is linked to the European
Commission’s “Europe for Patients” cam-
paign. It has been widely distributed among
EPF Member organisations, the European
institutions, and other relevant stakeholders
at both national and European level,and has
succeeded in raising significant interest at
national level. For example, in co-operation
with national parliaments, Poland, Lithu-
ania and Romania have hosted activities in
support of this initiative. EPF has also re-
ceived enquiries from patient organisations
in Serbia and Turkey who wish to use the
Manifesto as a basis for their own advocacy
work at a national level.
EPF has actively participated in the Pharma-
ceutical Forum, a three year process involv-
ing the European Commission, the Member
States and representatives from other stake-
holders to explore the future of pharmaceu-
ticals and public health in terms of informa-
tion to patients, pricing and reimbursement
and relative effectiveness. The conclusions
and recommendations of the Pharmaceuti-
cal Forum received political endorsement
during a high level ministerial meeting in
October 2008; and EPF co-organised with
the European Commission a Conference in
March 2009 on using the outcomes of the
Pharmaceutical Forum effectively.
Regarding the directive on cross-border
healthcare that passed its first reading
in the European Parliament on 23 April
2009, EPF worked with MEPs, Ministers
of Health from all EU countries, health
attachés and permanent representatives,
and supported a series of amendments of
interest to patients, including the need for
stronger co-operation between Member
States on cross-border healthcare and ex-
change of information and good practices,
the legal anchoring of principles of quality
and safety of health care, the introduction
of a European Patients’ Ombudsman, the
active involvement of patient organisations,
patient involvement in health technology
assessment etc. to ensure that the directive
becomes as inclusive and equitable as pos-
sible.
Currently, EPF is implementing the project
VALUE+ on the meaningful involvement of
patients in EU health projects,that is funded
under the Public Health Programme,as well
as the project RESPECT, that tries to iden-
tify the needs of children and their families
in clinical trials and to elaborate methods
by which these needs can be translated into
empowering and motivating participants in
future clinical trial research.
EPF is growing as a pan-European patient
body that defends the patients’interests and
needs in the European health debates. We
will enlarge our advocacy work and active
involvement in relevant health projects and
fight for patient-centred, equitable health
care throughout the European Union.
For more information on the Euro-
pean Patients Forum please consult:
www.eu-patient.eu
20
Regional and NMA news
EPF’s Value+ conference on meaningful pa-
tient involvement on December 9–10, 2009
in Gothenburg reported on the outcomes
of the two-year Value+ project, co-funded
by the European Commission. The Value+
project showed the need for enhanced po-
litical commitment to patient involvement
in EU health-related policies and projects at
all levels from local to EU level. Meaning-
ful patient involvement means putting the
patient at the centre of healthcare projects.
This results in positive project outcomes
which in turn contributes to patient-cen-
tred equitable healthcare policy-making
throughout the EU.
Perhaps more than any other policy area,
health policymaking has a huge impact on
the lives of individual citizens and patients.
Patients and patient organisations should
have a role in those decisions that will af-
fect their own lives and the community as a
whole. Patients’knowledge and personal ex-
perience bring clarity and a unique insight
to policy discussions.
Political representatives from the Swedish
Presidency and Poland, and officials from
the Member States, EU institutions, pa-
tient leaders and other stakeholders came
together at the conference for the unveiling
of three project deliverables which include
the Value+ Toolkit to support patient and
patient organisations in getting involved
in health related projects and policy, the
Value+ Handbook aimed at project coor-
dinators and leaders to show them how to
involve patient organisations and work ef-
fectively with them. And thirdly, the Policy
Recommendations which are the result of
the findings in relation to the assessment of
patient involvement in health projects sup-
ported by the European Commission.
Patient organisations support the policy
recommendations aimed at the European
Commission, European Parliament, Euro-
pean Council and Member States. Through
the recommendations,EPF is calling for ac-
tion to ensure patient involvement is inte-
grated in the health policy-making process
and programmes.
A new EU level policy instrument should•
include a code of best practice and guide-
lines to guarantee patient involvement at
all levels.
EPF believes that financial assistance•
should be required from the EU budget
to support patient groups in their partici-
pation in the political process.
The EU should create a European Centre•
on Patient Involvement to facilitate the
transfer of best practice to provide infor-
mation and capacity building.
Speaking at the conference, Göran Häg-
glund, Swedish Minister of Health and
Social Affairs reflected on patient centred
equitable healthcare in Sweden and noted
some important measures taking place that
reflect increasing patient empowerment
and patient involvement. He highlighted
shortening waiting times for access to dif-
ferent treatments, increasing in the number
of healthcare providers, patient safety, and
the importance of reaching an agreement
regarding patient rights on the cross border
healthcare directive as key priorities.
The European Commission has recognised
the need for patient involvement in health-
related policymaking in its White Paper
‘Together for Health: A Strategic Approach
for the EU 2008-2013’ which claims that
healthcare is becoming increasingly patient-
centred. Community health policy needs to
begin with patients’ rights, which include
participation and influence on decision-
making. Although there is a growing trend
within the European Commission towards
patient involvement, more needs to be done
not only within the Institutions. Support
from other stakeholders and patient groups
in understanding the role of patients is also
needed.
EPF President Anders Olauson stated that
“during recent years, the patients’ voice and
views have been recognised increasingly
as not just important, but a core require-
ment in health policy development. There
is however a gap between the recognition
that the patients’ experience and expertise
are a crucial part of the quality/sustainabil-
ity equation, and how to do this effectively
and transparently in policy and in practical
terms”.
The conference may have marked the end of
EPF’s 2-year EU-funded project on patient
involvement, but in many ways it marked
the beginning of new networks, new part-
nerships and a new way of thinking on pa-
tient involvement.
For further information and updates of
the project deliverables, visit the European
Patients’ Forum (EPF) website at www.
eu-patient.eu. EPF is a not-for profit, in-
dependent organisation and an umbrella
representative body for patients’ organisa-
tions throughout Europe. Representing the
EU patient community we advocate for pa-
tient-centred equitable healthcare and the
accessibility and quality of that healthcare
in Europe.
Nicola Bedlington, EPF’s Executive Director
EPF value+ conference confirms
the importance of patient
involvement in EU health-
related policies and programmes
Göran Hägglund, Swedish Minister
of Health and Social Affairs and EPF
President Anders Olauson
21
Regional and NMA news
Isabel Caixeiro
The European Union of General Practitio-
ners/Family Physicians (UEMO) represents
the European General Practitioners and
Specialists in Family Medicine in Europe.
Created in 1967, our members are the in-
dependent and most representative national
organizations representing General Practi-
tioners/Family Physicians in the European
countries. At present, the following coun-
tries are represented at the UEMO:
Austria Iceland Slovakia
Belgium Ireland Slovenia
Bulgaria Italy Spain
Croatia Lithuania Sweden
Czech
Republic
Luxembourg Switzerland
Denmark Malta Turkey
Finland
The
Netherlands
United
Kingdom
Germany Norway
Hungary Portugal
The UEMO’s core mission is to study and
promote the highest standards of training,
practice and patient care within the field
of general practice/family medicine and to
defend the role of general practitioners/
family physicians in the healthcare systems.
UEMO advocates for the ethical, scientific,
professional, social and economic interests
of European GP/FPs and protects their
freedom of practice, all in the interest of
their patients.
UEMO stands for the united views of its
members and represents them through the
appropriate channels before the relevant
European authorities and international or-
ganisations. In this context, UEMO seeks
to work closely with other European medi-
cal organizations (CPME, UEMS, FEMS,
PWG) and WHO-Europe.
In the period 2007-2010,Portugal is respon-
sible for the presidency of UEMO, with the
involvement of the UEMO steering team:Is-
abel Caixeiro (President), Luís Filipe Gomes
(Secretary General) and Manuela Santos
(Treasurer). The Board is also composed of
Vice-Presidents Henry Finnegan (Ireland),
Eirik Bø Larsen (Norway), Ferenc Hajnal
(Hungary) and Francisco Toquero (Spain).
The current presidency has set ambitious
goals for this four-year mandate. Hence,
definition of priorities, strategies and main
actions are being actively defined and pur-
sued with the involvement of all UEMO
members.
The Portuguese Presidency highlighted as
priorities for UEMO:
Recognition of the General Practice/•
Family Medicine as a specialty with the
development of specialist postgradu-
ate training curriculum in all European
Union countries, and update of Directive
2005/36/EC, of 7 September 2005 on
professional qualifications;
Full development and implementation –•
in accurate technical terms (job/tasks
description) – of the core content for the
European General Practitioner/Family
Physician and its implications at ethical,
organisational, training, quality assurance
and appropriate technology levels;
Development of the status of General•
Practice in Europe, at all levels;
Promotion of General Practice/Family•
Medicine in the undergraduate medical
curriculum;
International co-operation within Gen-•
eral Practice/Family Medicine organisa-
tions and with other medical organisa-
tions in Europe
UEMO’s activities and main areas of in-
tervention are:
The value of highly qualified General Practi-
tioners/Family Physicians
There are many opportunities for General
Practitioners/Family opportunities to de-
velop their professional role and ensure that
their full potential is realized. They are in-
creasingly involved in promoting the best use
of health systems resources and continuity of
care for the benefit of patients.Ideally,every-
one should have the possibility to choose a
personal Family Physician and to maintain
a solid relationship with that practitioner for
as long as they wish. The Family Physician is
the critical first contact for most health prob-
lems as well as for continuing care.
UEMO – A common European voice for
General Practicioners/Family Physicians
The Presidency team of the UEMO:
At the centre, Dr. Isabel Caixeiro, President.
To her right side, Dr. Luis Filipe Gomes, Sec-
retary-General and to her right Dr. Manuela
Santos, Treasurer.
22
Regional and NMA news
At the same time, there are many compel-
ling reasons to promote wide dialogue be-
tween General Practitioners/Family Phy-
sicians and other specialists, fostering the
performance of complementary roles,which
is essential for the interests of patients.
Because General Practitioners/Family Phy-
sicians cover a wide range of tasks within
the framework of healthcare systems, con-
cerns may arise related to how to address
the quality and status of general practice in
the different countries.
A glance to the recent history of General
Practice/Family Medicine clearly demon-
strates that this activity is gradually becom-
ing one of the more complex areas in the
medical practice. The risk of falling into
lower practice standards must be mitigated.
General Practitioners/Family Physicians
must deal effectively with undifferentiated
problems, co-morbidity, polipharmacy, so-
phisticated biomedical and psycho-social
phenomena, and psychosomatic problems.
They must also be attentive to opportunities
for preventive interventions, health promo-
tion and health education.
This broad professional role requires high-
level training programmes, continuing edu-
cation and quality assurance activities, simi-
lar to those associated with other medical
speciality training – an issue that is crucial
for health systems’response and sustainabil-
ity across Europe.
In some European countries, the recogni-
tion of General Practice/Family Medicine
as a medical speciality remains an ongoing
debate, involving medical organisations,
governments and academic bodies. Nev-
ertheless, there is a consistent movement
towards the specialization of General Prac-
titioners/Family Physicians, which is a new
landmark in health systems’ organization
and will contribute new approaches to pri-
mary care settings. A recent survey carried
out of UEMO members reports as follows:
Country
National recognition
of GP/FM as speciality
Austria NO
Belgium NO
Bulgaria NO
Croatia YES
Czech Republic YES
France YES
Denmark YES
Finland YES
Germany YES
Hungary YES
Iceland YES
Ireland YES
Italy NO
Luxembourg NO
Malta YES
The Netherlands YES
Norway YES
Poland YES
Portugal YES
Slovakia YES
Slovenia YES
Spain YES
Sweden YES
Switzerland YES
Turkey YES
United Kingdom YES
UEMO has actively promoted a number
of activities aiming to encourage the GP/
FM specialty to be acknowledged as a peer
of the other medical specialties at EU level,
namely in common provisions of the Direc-
tive 2005/36/EC, dated as of September
7, 2005 on the recognition of professional
qualifications. UEMO also supports na-
tional efforts in those countries seeking to
develop GM/FM specialty.
Mobility of health care professionals and patients
The European health systems face a set of
new challenges resulting from the abolition
of borders across the European territory,
globalisation, and migration of populations
looking to raise their socio-economical sta-
tus. Well-prepared General Practitioners/
Family Physicians have a major role to per-
form in this new era, in which primary care
must be the anchor of affordable and sus-
tainable health care systems.
Freemovementofdoctorsandofotherhealth
care professionals due to mutual recognition
of diplomas, in particular within the EU, still
raises some questions associated with qual-
ity, professional liability, and transparency of
qualifications. Regardless of the significant
moves forward, countries and authorities
have yet to effectively reinforce mutual co-
operation in a way that best safeguards the
public interest, establishes efficient and suit-
ably dimensioned health care services, and
ensures patient safety. The global shortage
of health professionals cannot be solved by
encouraging mobility, which will only lead
to brain drain in the less developed countries
though massive migration of their much
needed medical workforce.
At the Primary Care level, health systems
still need to work on their mutual coopera-
tion to promote a comprehensive and ra-
tional approach on mobility. As mentioned
above, the recognition of the specialty of
General Practice/Family Medicine by the
European legal framework is fundamental
to promote actual mobility of General Prac-
titioners/Family Physicians. Without that
provision, GP/FPs’mobility will be reduced
and based on lower qualification require-
ments.
Patients’ interests must also be assured by
means of clear and accountable measures
that on one hand allow patient mobility
across borders as an option for the patient,
but which on the other hand do not force
him to seek health care in another country.
There may be good and various reasons to
seek health care in another country, but pa-
tients should be able to find continuity of
care in or close to his or her community.
23
Regional and NMA news
Empowerment and autonomy of citizens con-
cerning personal and collective health matters
Promotion of patients’ rights in Europe is a
strong social and political issue. Patients are
also being asked to take more responsibil-
ity for their own health. This requires more
education and information, and efforts to
protect patients from an uncontrolled self-
medication market and the risk of polip-
harmacy.The empowerment of patients can
only be effective if it is grounded in a solid
doctor-patient relationship in a system ca-
pable of providing personalised, affordable
and qualified health care.
These are clearly subjects already ap-
proached by the UEMO and that require
continuous attention in the near future. As
a partner of European Institutions in health
fields, UEMO will monitor and advise on
all issues related to primary care impacts
and enhanced health care provided by Gen-
eral Practitioners/Family Physicians, in the
interest of patients and for the purpose of
health interventions towards health gains.
Increasing demand for cost-effectiveness and
quality, grounded in universal access to health
care
There is currently some tension around the
“gate-keeper” concept that exists in some
European countries,as a result of very differ-
ent medical cultures that vary from country
to country. Because the tradition of free ac-
cess to any specialised care has been a reality
for many years, concern has been expressed
that General Practitioners/Family Physicians
could be advocating misuse and promoting
limited access to other medical specialized
care merely for cost-containment reasons.
However, the increasing labyrinth of medi-
cal technology available to the population
and its significant impact at social and eco-
nomical levels demand that General Practi-
tioners/Family Physicians support and guide
patients through a range of complex options.
The success of health systems in these top-
ics should be promoted through informa-
tion and education, rather than by coercion
or prohibition. Facilitator mechanisms can
be more helpful to meet the demand of uni-
versal access to quality and cost-effective care
than administrative restrictions.
Funding models and specific interests of the
various health care players have established
distinct organisational lay-outs in which
competition inhibits cooperation. Never-
ending debates will continue around major
themes like sustainability, funding, qual-
ity, and health provision. However an effort
should be made to find innovative solutions
emphasising co-operation over competition.
Considering this scenario,General Practitio-
ners/Family Physicians are clearly indispens-
able to achieving cost-effectiveness in health
care and to co-operating and coordinating
efforts in the best interest of patients.
Information & communication technologies in
healthcare
The widespread integration of information
technologies into daily health care environ-
ment raises a broad range of expectations,
nevertheless one should be aware that, while
they may solve some health problems, they
may magnify others, and that they may
cause added strain to health systems, profes-
sionals and patients. Recently implemented
features such as electronic health records,
telemedicine and remote medicine, expert
systems, smart cards and data protection are
undoubtedly influencing and shaping the
future of General Practice/Family Medicine.
European countries have been trying to deal
with this unceasing influx of technologies
by developing a number of national projects
alongwithglobalEuropeanprojects.UEMO
has a clear vision of this emerging field and
considers the appropriate use of technology
as an improvement. It is clearly a valuable
tool in facilitating primary care investigation
faster when needed and improving com-
munication between primary and second-
ary care levels, though major aspects such as
data protection and confidentiality of health
records must be carefully considered.
The future role & strategy of the UEMO
As the main representative of General
Practitioners/Family Physicians in Europe,
UEMO continues to establish itself as a
critical link to the EU health institutions,
the European Parliament and the European
Commission. UEMO is already fully incor-
porated as a non-profit organisation under
the Belgian law, which will significantly re-
inforce the voice of General Practitioners/
Family Physicians at the EU level.
The UEMO seeks to represent all European
General Practitioners/Family Physicians
and is therefore actively looking for new
members coming from as yet unrepresented
countries. Wider representation allows the
organisation to circulate its input more ac-
tively from the practice level in GP/FM to
the policy and steering level. UEMO also
understands that closer cooperation with
other European Health Organisations as
well as with global health entities such as
the World Medical Association and the
World Health Organisation is fundamental
to the common development of a clear pri-
mary care agenda at EU level.
That is the reason why the UEMO has
been seeking to improve coordination with
WONCA and EURACT – as a first step,
working together with these entities will
influence positively the qualification of cur-
rent and future General Practitioners/Fam-
ily Physicians, in the area of more appro-
priate and evidence-based interventions in
health care and patient interest.
UEMO is also involved in fostering recruit-
ing strategies and policies for new GP/FPs
and has therefore engaged in strengthening
bonds with the Vasco da Gama Movement
that emerged from coordinated efforts of
WONCA-Europe and EURACT to dis-
seminate, promote, and develop the GP/
FM specialty in Europe.
As a representative medical organisation,
UEMO maintains and promotes united
24
Regional and NMA news
views amongst medical organizations and
regularly meets and debates common posi-
tions with CPME, UEMS, FEMS, EANA,
CEOM, AEMH and PWG. A strong,
coherent and active position of all doctors
is a paramount to reinforcing trust of the
European health systems and the provided
health care services among patients and
other health stakeholders.
After 40 years of continued activity pro-
moting primary care and General Practi-
tioners/Family Physicians medical practice,
UEMO’s Portuguese Presidency is currently
engaged in further developing this mission.
Each and every one of the UEMO activities
is a solid contribution to the overall goal of
“serving the interests of patients”, which is
not only the mandatory requirement for all
medical interventions, but should also be the
driving force behind the policy and political
activities of the medical profession. General
Practitioners/Family Physicians, like Prima-
ry Care itself,are committed to ensuring that
health care activities are driven by the needs
of citizens and further the objectives of dis-
ease prevention and health promotion.
We work today to prepare the future.
Dr. Isabel Caixeiro, President
J. James Rohack
From the influenza pandemic and Fort
Hood shootings to the unforgettable trag-
edies of Sept. 11 and Hurricane Katrina,
our country has endured a number of cata-
strophic events and public health emergen-
cies in recent years.The good news is that as
these events continue to surface, physicians
and communities nationwide have contin-
ued their preparation for effective response.
In conjunction with the Health and Human
Services Public Health Emergency Medical
Countermeasures Enterprise Stakeholders
Workshop, the AMA recently hosted the
Third National Congress on Health Sys-
tem Readiness. Physicians and other stake-
holders in medicine, as well as government
and community leaders, joined the nation’s
leading public health preparedness experts
in Washington, D.C., to review current re-
search and science related to recent disasters
and public health emergencies worldwide,
and to establish a framework for response.
And they discussed how to manage and re-
spond to a real, yet unpredictable crisis we
now face – the 2009 H1N1 influenza pan-
demic.
The pandemic has received global attention
ever since the virus emerged in April 2009.
The AMA’s Disaster Medicine and Public
Health Preparedness journal just published
a special issue about the pandemic, includ-
ing articles on point-of-care testing and
biothreats, pediatric considerations in ex-
tending and rationing care in public health
emergencies, and operational consider-
ations in mass prophylaxis work force plan-
ning. And the AMA’s Pandemic Influenza:
A primer and resource guide for physicians
and other health professionals provides in-
sightful recommendations on preparedness
and response to an influenza pandemic.
In light of recent events, a group of phy-
sicians agreed during the AMA’s disaster
medicine caucus at the Interim Meeting
of the AMA House of Delegates in Hous-
ton that all health professionals and local
communities need the proper training and
resources to know what to do in these situ-
ations. Fortunately, the right tools and edu-
cation are already under way.
The AMA, in cooperation with four major
medical centers,established the National Di-
saster Life Support™ (NDLS™) Program
in 2003 to standardize emergency response
training and strengthen our nation’s public
healthsystem.Summoningmorethan75,000
participants, the program has 70 training
centers throughout the United States that
offer the NDLS™ Program courses.
One component of this program, the Ad-
vanced Disaster Life Support™ (ADLS®)
Course, has been revised to include train-
ing in mass triage, hospital response and
planning, surge capacity, and skills stations
and clinical scenarios, and is expected to be
available to the public in June.
For individual citizens, the CitizenReady™
program, developed collaboratively by the
AMA, the Federal Emergency Manage-
ment Agency and the National Disaster
Life Support Foundation, Inc., is being pi-
loted in cities and towns across the country
via an initial program that focuses on the
influenza pandemic.
As we’ve seen from experience, disaster can
strike at any time – and without notice.The
best way to ensure that our patients, homes
and communities are safer is preparation.
Have a plan. Practice it. And be ready.
J. James Rohack, MD, President of the AMA
This column originally appeared in
the Dec. 4 edition of AMA eVoice.
Gearing up for emergencies – a vital
component to our nation’s health
25
Regional and NMA news
The 26th
Confederation of Medical Asso-
ciations in Asia and Oceania (CMAAO)
Congress and 45th
Council Meeting was
held in Bali, Indonesia, from November 5th
to 7th
, 2009. The Congress was attended by
50 representatives from 12 NMAs (Japan,
Hong Kong, India, Indonesia, Republic of
Korea, Malaysia, Myanmar, New Zealand,
Philippines, Singapore, Taiwan, and Thai-
land). The Council Meeting took place on
the 5th
and the Congress Grand Opening
Ceremony and Assembly Meeting were
held on the 6th
,with the meeting continuing
on the 7th
, followed by the symposium.
One of the main events of the Congress
was the passing of the Presidential Medal
from Immediate Past-President Dr. Somsri
Pausawasdi of the Medical Association of
Thailand to the new President, Dr. Fachmi
Idris of the Indonesian Medical Associa-
tion, during the Grand Opening Ceremony
on the 6th
.Following that,the 9th
Taro Take-
mi Memorial Oration was presented. This
is an oration event commemorating Dr.
Taro Takemi, a Japanese doctor who served
as president of JMA for 25 years and con-
tributed to the establishment of CMAAO.
Dr. Azrul Azwar, Professor at University of
Indonesia, CMAAO Past-President, and
WMA Past-President spoke on “The Role
of Primary Physician in Achieving the Mil-
lennium Development Goals (MDGs)”.
At the Council Meeting, I presented a
report, as Secretary General, of the main
CMAAO activities for the past years. In
the report I spoke about the discussion
focused on the topic of the economic cri-
sis and healthcare, which was the theme of
the symposium during the Congress. I also
touched upon the topics of task-shifting
and prescription rights, which are also be-
coming issues for the WMA, and the anti-
smoking issue, which is an issue common to
all countries. Representatives of the NMAs
also delivered a Country Report of their
NMA’s activities for the past year.
The application of the Myanmar Medical
Association for CMAAO membership was
approved, bringing CMAAO membership
to 18 NMAs.
The main agenda for the Congress also
included some organizational issues, such
as consideration of how and when future
Congresses and Mid-term Council meet-
ings should be held and how executive
board members should be selected with a
view to strengthening CMAAO’s organi-
zational structure. Since these reforms in-
volve matters requiring broad changes to
the CMAAO Constitution & By-laws for
operation, it was decided that the Constitu-
tion & By-laws Committee would take the
central role in preparing a draft proposal,
and that revision would be carried out at
future CMAAO meetings.
With regard to the main items currently
being considered by CMAAO, it was de-
cided to divide the responsibility of pre-
paring proposed statements on important
topics among NMAs. In particular, it was
agreed to make the anti-smoking problem,
which is common to all member NMAs, a
permanent theme and continue discussions
at future meetings. Moreover, to facilitate
more efficient utilization of the CMAAO
website, a decision was made that all mem-
ber NMAs should prepare reports of their
activities and proactively send them to the
Secretariat at the Japan Medical Associa-
tion.
With respect to future meetings, the 46th
CMAAO Mid-term Council Meeting will
be held Kuala Lumpur, Malaysia, in 2010
and the 27th
CMAAO Congress will be
held in Taipei (Taiwan) in 2011.
A symposium entitled “Impact of the Fi-
nancial Crisis on the Health System” was
also held, with presentations by representa-
tives of nine NMAs.
In addition, elections were held for Office
Bearers for 2009-2011, the results of which
are shown below.
Masami Ishii, MD
Secretary General of CMAAO
Vice-chair of WMA
Report of the 26th
CMAAO Bali Congress
Note by the Secretary General
CMAAO Office Bearers for 2009–2011
President Fachmi Idris Indonesia
President-Elect Ming-Been Lee Taiwan
Immediate Past-President Somsri Pausawasdi Thailand
1st Vice President David Kwang-Leng Quek Malaysia
2nd Vice President Dong Chun Shin Korea
Chairman Wonchat Subhachaturas Thailand
Vice-Chairman Peter Foley New Zealand
Treasurer Yee Shing Chan Hong Kong
Secretary General Masami Ishii Japan
Assistant Secretary General Hisashi Tsuruoka Japan
Adviser Tai Joon Moon
Yung Tung Wu
Korea
Taiwan
26
Regional and NMA news
Introduction
The official English-language Journal of the
Japan Medical Association, JMAJ was first
published in 1958 as Asian Medical Jour-
nal (AMJ) to advance medical science and
healthcare in Asia and to strengthen the in-
fluence from abroad on Japan’s health poli-
cies by introducing JMA’s policies. At that
time, JMA had a strong leader, Dr. Taro
Takemi, who served as the JMA president
for an exceptionally long period of 25 years
(1957-1982).He was actively engaged in in-
ternational affairs, held the WMA General
Assembly Tokyo in 1975 and became the
29th
WMA president. Under his leadership,
the foundation of international activities of
the JMA was built including participation
in the World Medical Association (WMA,
1951), creation of Confederation of Medi-
cal Associations of Asia and Oceania
(CMAAO, 1956), and the establishment
of Takemi International Health Program in
Harvard School of Public Health (HSPH,
1983) [1].
The JMA publishes another journal in Japa-
nese, the Journal of the JMA. The Japanese
journal has a peer review system for original
contributions while JMAJ currently does
not. Both journals mainly publish invited
review articles, but the readership of the
Japanese journal is mainly JMA members
while JMAJ is published for global readers,
mostly outside of Japan.
Scientific journals on general medicine
published in Japan are not so highly eval-
uated internationally. Some people argue
that the JMA should publish a medical
journal that would be internationally rec-
ognized.Therefore, we decided to conduct
a survey questionnaire on periodicals pub-
lished by National Medical Associations,
in collaboration with the Takemi Program
in HSPH, to clarify what periodicals
NMAs publish, with a focus on explor-
ing unique approaches and effective ways
to transmit useful health information to
global readers.
Summary of the Survey
on NMA Journals
This section presents some results related to
the NMA characteristics and their journals
on general medicine.The full report is avail-
able in the JMAJ 2009;52(4) [2].
In October 2008 we emailed a question-
naire to all 92 NMAs in the WMA and
CMAAO, and received responses from 31
(34%).
Table 1 provides the numbers of NMA
members and staff. Membership ranged
from the smallest, Luxembourg (1,150) to
the largest, Germany (395,000). Of the 29
NMAs that reported their type of member-
ship, 86% (25) responded that it was vol-
untary.The US had the largest staff (1,000),
far more than that of the runner-up, the
UK (450) and other NMAs. Staff density is
the number of staff per thousand physician
members.
Approximately 71% of the journals (20/28)
had five staff members or fewer. The jour-
nals with the largest staffs were JAMA (100,
US),BMJ (40,UK) and CMAJ (32,Canada)
[2], followed by India and Norway (20) and
the Netherlands (15).
Sources of published articles in NMA jour-
nals are shown in Table 2. Overall, the ma-
jority of published articles were contributed
by “outside authors” or general manuscript
submissions from authors who did not work
for the journal. Among the 29 journals that
reported the peer review percentage, 66%
(19) peer reviewed more than 90% of their
articles [2].
The official languages of the WMA are
English, Spanish and French (the official
language of the CMAAO is English).In all,
69 NMAs (75%) used English as their of-
ficial language, followed by Spanish (16/92,
17%) and French (7/92, 8%). Approximate-
ly 71% (22/31) of journals were published
either partly or fully in English [2].
Among the 26 journals that reported online
availability, full text was available for free in
73% (19) (Figure 1). In the case of JMA,
the English journal is freely available, but
the Japanese journal is open to its members
only.
What can medical journals
do for global health?
Mieko HamamotoMasami Ishii
27
Regional and NMA news
Thus, we have found that the numbers of
people and participation rates of NMAs
varied widely, but approximately 70% of
the NMA journals had five or fewer staff
personnel, used English at least partly, and
were freely available online. According to
the self-reported classification, 16 journals
were defined as journals published mainly
for domestic readers and 15 journals were
for global readers [2]. Of the 26 NMAs,
only 4 NMAs, including Japan, published
two or more general medical journals both
in their native language and English [2].
The survey did not capture the complete
global picture on NMAs and their periodi-
cals, with only 2 responses out of 16 NMAs
in Latin America, none from Africa (12),
and missing data on each question. Never-
theless, it has strength as the first interna-
tional comparative survey of this sort,which
collected a wide range of data, with friendly
cooperation of WMA and CMAAO – the
two international organizations represent-
ing physicians.
Factors for Success
What is success for journals published by
medical associations, and how do we mea-
sure it? As Sir William Osler once said,
“the practice of medicine is an art, based on
science”[3]. Here we review two journals
from the concepts, science and art.
New England Journal of Medicine
The NEJM is one of the most successful
scientific journals on general medicine, with
the oldest history since 1812 and the high-
est impact factor (52.589 in 2007) [4]. The
publisher, the Massachusetts Medical So-
ciety, has 21,291 members as of 2008 and
over 400 staff members [5], with high staff
density of 18.79.
The secret of the journal’s success is acci-
dental – Mr. Stephen Morrissey, Manag-
ing Editor of the NEJM responded, after
a little pause, in the interview conducted
by Hamamoto in May 2009. He also char-
acterized the journal by its operation with
almost all sections in-house except print-
ing, and especially emphasized the graphic
section producing superb illustrations. Un-
like typical commercial publishers, they are
basically citable for free, creating a virtuous
circle where citations breed citations.
Table 2. Sources of Published Articles (n=29)
Area* Journal**
Outside
Authors
Edi-
tors
Invited
Articles
Pacific G 98% 0% 2%
Pacific G 90% 5% 5%
Pacific G 90% 2% 8%
Asia G 90% 0% 10%
Euro D 90% 5% 20%
Asia G 90% 5% 5%
Asia G 90% 5% 5%
Latin Am D 85% 10% 5%
Euro D 80% 20% 0%
Euro G 70% 15% 15%
Euro D 70% 20% 5%
Euro D 70% 15% 15%
Euro D 68% 0% 6%
Asia G 65% 0% 35%
Asia D 50% 40% 10%
North Am G 33% 33% 33%
Euro D 30% 20% 40%
Pacific D 30% 50% 20%
Euro G 5% 90% 0%
Pacific D 5% 0% 95%
Pacific
(J of the JMA)
D 3% 0% 97%
Pacific D 0% 50% 50%
Pacific
(JMAJ)
G 0% 0% 100%
Euro G yes yes yes
Asia G yes yes yes
Euro G yes yes yes
North Am G yes yes no
Asia D yes yes yes
Euro D yes yes yes
Mean 57% 17% 25%
Median 70% 5% 10%
* Journal names have been kept anonymous except Japan.
** G stands for global journal and D for domestic journal,
based on the NMA’s definition.
Table 1. Numbers of NMA Members and Staff
No. of Members Participation Rate
(%)
No. of Staff Staff Density
Australia 26,000 (50) 42 1.62
Azerbaijan 1,480 (5) 8 5.41
Bangladesh 35,000 (80) 120 3.43
Belgium – (25) 10 –
Brazil 120,000 (36) 45 0.38
Canada 69,000 (70) 170 2.46
Czech Republic – – 23 –
Germany 395,200 (100) 100 0.25
Hong Kong 7,557 (70) 25 3.31
Hungary 30,000 (95) 11 0.37
Iceland 1,254 (99) 5 3.99
India 175,000 (27) 85 0.49
Israel 18,000 (94) 70 3.89
Japan 165,086 (60) 189 1.14
Korea 75,476 (80) 137 1.82
Luxembourg 1,150 (73) 3 2.61
Macedonia 4,500 (75) 3 0.67
Malaysia 7,897 (36) 22 2.79
Netherlands 38,906 (58) 137 3.52
New Zealand 4,000 (40) 10 2.50
Norway 22,055 (97) 120 5.44
Philippines 28,000 (50) 22 0.79
Spain 206,000 (96) 25 0.12
Sri Lanka* 3,000 (20) 10 3.33
Switzerland 33,655 (98) 71 2.11
Taiwan 37,518 (100) 32 0.85
United Kingdom 138,000 (64) 450 3.26
United States 231,000 (33) 1,000 4.33
Uruguay 8,500 (60) 26 3.06
No. of responses n=27 n=28 n=29 n=27
Mean 69,749 (64) 102 2.37
Median 30,000 (67) 32 2.5
* Sri Lanka is a member of CMAAO only.
28
Regional and NMA news
But the journal obviously has a geographical
advantage; in addition to an editorial board
consisting of international members, it has
editors, most of whom are practicing in
hospitals in the Boston area or teaching in
Harvard and other schools. They attend the
editorial meeting every Thursday afternoon.
However common online communications
have become, it is a great advantage to have
editors and staff within a short distance that
enables them to meet face to face easily. Its
longstanding success must be an accident
caused by that certain environment in Bos-
ton, USA.
World Medical Journal
The WMJ must have gone through vari-
ous transitions since the first publication
in 1949 [6]; a discussion as to the title of
WMA’s official publication [7] and a pro-
posal to transform the WMJ into an inter-
national peer-reviewed journal [8] in 2006
are still fresh in our minds.
Dr.Pēteris Apinis,the new Editor-in-Chief
since 2008, President of the Latvian Phy-
sicians Association and the former Health
Minister of Latvia, reported that the WMJ
aims to become a powerful information
spreader of world medicine, with three key-
words: informative, interdisciplinary   and
actual [9]. He actively asks colleagues for
contribution of manuscripts, and was wit-
nessed walking around the rooms with a
camera in his hands to patiently excavate
the faces of participants and information
from all parts of the world in the WMA
meetings.
The WMA General Assembly New Delhi
2009 adopted WMA Declaration of Delhi
on Health and Climate Change,and elected
Dr. Ketan Desai from India as President of
the WMA for 2010-11. Many participants
must have felt a growing interest in social
medical issues, and the power of India, a
rising nation with more than one billion
people.
For the WMJ to achieve its goal, scientific
evaluation is hard to make, and whether
the title should be journal or bulletin is not
important. It will have a significance and
originality in the art of medicine including
human nature, by covering WMA’s reality
and voices of physicians across the globe.
Concluding remarks
Medical journals have various directions to
head, and we often know little about what
is necessary to go in that direction. It is not
easy to make the journal sustainable and of
the highest quality because our resources are
limited. NEJM represents an ideal form of
scientific journals, and WMJ has strength
in human network spreading around the
globe. JMAJ will maintain the current poli-
cy, closely associated with WMJ. We believe
that NMAs can turn information accumu-
lated in each country into a shared asset of
the world through more vocal, online and
off-line communication.
Acknowledgments
We would like to express our sincere ap-
preciation to all the NMAs, Otmar Kloiber
and Sunny Park for their cooperation to the
survey.We would also like to thank Michael
R. Reich and Hisashi Tsuruoka for their
valuable comments.
References
1. Takemi Program in International Health. http://
www.hsph.harvard.edu/research/takemi/ (accessed
Dec 2009).
2. Hamamoto M, Jimba M, Halstead D, et al. Can Na-
tional Medical Association Journals Make Greater
Contributions to Global Health? An international
survey and comparison. JMAJ.2009;52(4): 243–258.
3.Osler W.Aequanimitas with other addresses to medi-
cal students, nurses and practitioners of medicine.
Philadelphia: P. Blakiston’s Son & Co; 1905:36.
4. Journal Citation Reports. ISI Web of Knowledge
(JCR Science Edition 2007. Subject category: Medi-
cine, General & Internal). Thomson Reuters.
5. AbouttheMassachusettsMedicalSociety.http://www.
massmed.org/AM/Template.cfm?Section=About_
MMS (accessed Dec 2009).
6. Boston L.The National Medical Journal as Interme-
diary. Journal of the JMA.1980. (Japanese translation
from WMJ 1979;26(6).
7. Rowe A. The Title of the World Medical Associa-
tion House Regular Publication. (WMA Document.
FPL/WMJ Title/May2007). Nov 2006.
8. Davis R. Proposal to Revamp and Relaunch the
World Medical Journal. (WMA Document: Propos-
al to Change the Format of The WMJ. FPL/WMJ
Future/May2007). Nov 2006.
9. Apinis P. Dear colleagues throughout the world!
WMJ. 2008;54(1):1
Mieko Hamamoto, International Affairs
Division, Japan Medical Association,
Masami Ishii, MD, Executive Board Member,
Japan Medical Association.
Vice-chair, World Medical Association.
Secretary General, CMAAO
Figure 1. Online Availability of NMA Journals (n=26)
29
Regional and NMA news
In recent years many have asserted that the
right to health is a critical element of peace-
ful societies and that health professionals
have a role to play in peace processes. In
1998 the 51st World Health Assembly for-
mally accepted Health as a Bridge for Peace
as a feature of the “Health for All in the
21st Century” strategy. According to the
World Health Organization “health can be
a neutral meeting point to bring conflicting
parties to discuss mutually beneficial inter-
ventions”.
Efforts to engage the medical profession
across geographic and political boundaries
have been underway for several years. The
Norwegian Medical Association organized,
under the auspices of the World Health
Organization, five meetings from 1993 to
1997 among the medical associations from
the new republics in former Yugoslavia.
The underlying theory for these meetings
was that physicians have ethical standards
in common that go beyond ethnic and na-
tional interests.
In 2007 Brazil, France, Indonesia, Senegal,
South Africa,Thailand and Norway formed
an alliance to put health on the global for-
eign policy agenda. They stated that “The
world is facing many common problems re-
lated to health, and therefore foreign policy
must be more health sensitive.” This group
identified a number of elements that de-
serve greater attention:
development and use of health indicators•
to better assess peace and reconstruction
processes;
roadmaps for health recovery as a peace-•
making tool;
more empirical knowledge of the effect of•
health intervention at different stages in
conflicts. 
Most recently, from 27-30 October 2009,
the World Medical Association and medi-
cal associations and health and human
rights organizations from Egypt, Iraq, Is-
rael, Netherlands, Norway, Palestine and
Turkey met in Kuşadaşi in Turkey to discuss
health as a bridge to peace in the region.
The purpose was to stimulate and improve
communication among health profession-
als in the region, as a first step in a process
we hope will establish collaboration struc-
tures among medical associations in Middle
East.
Before the conference in Turkey, all partici-
pating organizations completed a question-
naire on the right to health in their country.
The meeting began with a presentation of
the survey results. Each organization high-
lighted two or three items related to health
and human rights, which then formed the
basis for the discussion agenda.
The conference provided a forum for valu-
able dialogue and exchange of information
and experiences in the area of the right to
health. Different countries face different
challenges and during the discussions the
political realities, particularly in Israel and
Palestine, often surfaced. One of the main
objectives of the meeting was to establish a
common project on which the participants
could collaborate. Various suggestions for
future projects were discussed:
training physicians on ethics and human•
rights;
initiating�����������������������������������activities to increase the profes-•
sional capacities of physicians who play
an important role in the prevention of
torture;
monitoring the implementation of two•
recent WHO resolutions – the first on
the revitalization of primary health care
as the key element of comprehensive
health care systems and the second on the
social determinants of health;
addressing the negative impact of war,•
conflict and violence on the health of the
population;
analysing health disparities in different•
countries of the Middle East;
holding governments accountable for re-•
alizing the right to health.
Toward the end of the conference it became
clear that it was difficult to find one project
all could agree on. The participating or-
ganisations found the meeting valuable, but
would need more time for building trust and
getting to know each other better. However,
the participants agreed to continue to meet,
and realised the necessity of dialogue in
order to establish sustainable collaboration
structures on the issue of right to health.
It was decided that the topic for the next
meeting should be: The role of health per-
sonnel in health and human rights.
The meeting was co-organized by five orga-
nizations: two National Medical Associations
(the Norwegian Medical Association and the
Turkish Medical Association),one national hu-
man rights organization (the Human Rights
Foundation of Turkey) and two international
networks: the International Federation of
Health and Human Rights Organizations and
the World Medical Association.
Bjorn Oscar Hoftvedt,
Metin Bakkalci,
Otmar Kloiber,
Eline Thorleifsson,
Adrian van Ees
The right to health as a bridge to peace in the
Middle East
30
Regional and NMA news
The Polish (Supreme) Chamber of Physi-
cians and Dentists (Naczelna Izba Leka-
rska) and the regional chambers of physi-
cians and dentists (okręgowe izby lekarskie)
are the organizational bodies of the profes-
sional self-government of physicians and
dental practitioners who are associated in
the chambers with equal status.
The professional self-government of phy-
sicians and dental practitioners in Poland
was founded in 1922, dissolved in 1952 and
reestablished in 1989. There are currently
23 regional chambers and a separate cham-
ber of military physicians and dentists that
has the legal status of a regional chamber,
though its members span the entire country.
Chambers of physicians and dentists address
a range of matters concerning the practice
of medicine and dentistry in Poland.
The highest authority of the Polish Cham-
ber of Physicians and Dentists is the Gen-
eral Medical Assembly, and the regional
medical assemblies are the highest authori-
ties of the regional chambers. In the period
between assemblies, the Supreme Medical
Council and regional medical councils are
the decision-making bodies at the state and
regional levels,respectively. Every physician
and every dental practitioner who holds the
right to practice the profession in Poland is
a member of one of the regional chambers
by virtue of the law.
Number of members of the chambers in
2009:
Physicians – 132 694;
Dental practitioners – 36 633;
Persons with both professional titles – 594.
The tasks of the self-government of physi-
cians and dentists include:
supervising the proper and conscientious•
exercise of the medical professions;
determining the principles of professional•
ethics and deontology binding all physi-
cians and dentists and overseeing compli-
ance;
representing and protecting the medical•
professions;
integrating the medical circles;•
delivering opinions on matters concern-•
ing public health, state health policy and
organization of healthcare;
co-operating with scientific associations,•
universities and research institutions in
Poland and abroad;
offering mutual aid and other forms of fi-•
nancial assistance to physicians and den-
tists and their families;
administering the estate and managing•
the business activities of the chambers of
physicians and dentists.
The Chambers:
certify the right to practice the profession•
of a physician or dentist and keep the reg-
ister of physicians and dentists;
negotiate conditions of work and remu-•
neration;
make decisions on matters relating to fit-•
ness to practice as a physician or dentist;
co-operate in the field of continuous•
medical education;
deliver opinion on draft legislation con-•
cerning health protection and exercise of
the medical professions;
deliver opinions and make motions re-•
garding undergraduate and postgraduate
training of physicians and dentists;
act as medical courts in matters involv-•
ing professional liability of physicians and
dentists;
defend individual and collective interests•
of members of the self-government of
physicians and dentists;
co-operate with public administration•
agencies, political organizations, trade
unions as well as other social organiza-
tions in matters concerning protection of
human health and conditions of practic-
ing medicine.
Organization of the Professional
Self-Government of Physicians and
Dentists in Poland
The organs and members of the Supreme Chamber
(term of office: 2006 – 2010)
Supreme Medical Council
Consists of 75 members – representatives of Polish physicians and dental practitioners
elected at the General Assembly.
President Dr. Konstanty Radziwill
Secretary Dr. Mariusz Janikowski
Vice-Presidents: Dr. Ryszard Golański,
Dr. Anna Lella,
Dr. Andrzej Wlodarczyk
Deputy Secretary Prof. Jerzy Kruszewski
Treasurer Dr. Andrzej Sawoni
Members of the Presidium: Dr. Zdzisław
Annusewicz, Dr. Romuald Krajewski,
Dr. Wojciech Marquardt,
Dr. Andrzej Matyja
Supreme Screener for Professional Liabil-
ity Dr. Jolanta Orlowska-Heitzman
Chairperson of the Supreme Medical
Court Dr. Jerzy Nosarzewski
Chairperson of the Supreme Audit Com-
mittee Dr. Jarosław Zawiliński
31
Regional and NMA news
International policy of the Polish
Chamber of Physicians and Dentists
One of the important areas of activities of
the Polish Chamber of Physicians and Den-
tists is participating actively in international
organizations of physicians and dentists and
collaborating with medical and dental orga-
nizations and chambers abroad.
The Chamber is active in the following
international organizations of doctors and
dental practitioners:
Standing Committee of European Doc-•
tors (CPME);
European Union of Medical Specialists•
(UEMS);
European Forum of Medical Associa-•
tions and the World Health Organiza-
tion (EFMA/WHO);
Symposium of Medical Chambers of•
Central and Eastern Europe;
World Medical Association (WMA);•
Council of European Dentists (CED);•
World Dental Federation (FDI);•
European Regional Organization of the•
World Dental Federation (ERO/FDI).
In 2008 the Chamber applied for constitu-
ent membership in the World Medical As-
sociation. The application was approved at
the General Assembly in Seoul in October
2008 and the Chamber became an active
WMA member again on January 1, 2009.
The Polish Chamber of Physicians and
Dentists was one of the founding WMA
member associations, though its member-
ship ceased when the Chamber was dis-
solved in 1952.
Dr. Konstanty Radziwill, President of the
Polish Chamber of Physicians and Dentists,
is a Vice-president of the Standing Com-
mittee of European Doctors (CPME) and
was elected to the position of the CPME
President for the years 2010 – 2011.
Since October 2008 Dr, Romuald Kra-
jewski,Member of the Presidium of the Su-
preme Medical Council, is currently serving
as Vice-President of the UEMS.
The Polish Chamber of Physicians and
Dentists also co-operates on regular basis
with national medical chambers and medi-
cal organizations from many other coun-
tries.
Provided by the Polish Chamber
of Physicians and Dentists
Ming-Been Lee
The celebrations of Doctors’ Day in Novem-
ber 2009 marked the year end for the Taiwan
Medical Association. However, the commit-
ment to end people’s suffering with improved
quality care is our never-ending mission, par-
ticularly during and after a disaster. In this ar-
ticle we review three major events that demon-
strateTMA’s interaction with the international
community,the pubic and our local peers.
Taiwan Medical Association
Celebrated Doctors’ Day
The TMA celebrated 2009 Doctors’Day on
12 November in the presence of Dr. Dana
W.Hanson,President of the World Medical
Association, Dr. Masami Ishii, Vice-Chair-
man of the WMA, Dr. Cecil B. Wilson,
President-Elect of the American Medi-
cal Association, Prof. Vivienne Nathanson,
Director of Professional Activities, British
Medical Association, and Dr. Dongchun
Shin, Chair, Executive Committee of In-
ternational Relations, Korean Medical As-
sociation. Nearly 500 senior doctors were
openly acknowledged for their four to six
decades-long contributions. The ceremony
highlighted ten outstanding physicians re-
ceiving the TMA Role Model Award and
compliments from distinguished foreign
guests.
Before the award giving ceremony was the
International Seminar on Health for All:
Problems and Solutions, chaired by TMA
President Dr. Ming-Been Lee. Focusing on
health insurance and the physician-patient
relationship,the seminar invited abovemen-
tioned international speakers and welcomed
broad participation from all over the coun-
try, including TMA’s boards of directors
and supervisors, international affairs com-
mittee, heads of regional branches and pro-
fessional medical societies to share and ex-
change views. Dr. Hanson, Dr. Ishii and Dr.
Shin provided overviews of the healthcare
systems in Canada, Japan and South Korea,
respectively. Dr. Wilson, drawing on the ex-
perience of AMA,provided in-depth analy-
sis on health policy making in the United
States, while Prof. Nathanson elaborated on
the experience of the doctor-patient rela-
tionship in the United Kingdom. The cel-
ebrations were honored by President Ma
Ying-jeou’s attendance in the afternoon.
Post-conference programmes for our guests
began with the Bureau of National Health
Insurance inTaipei,where the General Man-
ager Shou-Hsia Cheng received the visitors
with his vivid illustration on the operation
of NHI in Taiwan. The group also visited
the Buddhist Tzu Chi Hospital in Hualien
on the east coast and learned about their
worldwide humanitarian work. The tour ex-
Messages from Taiwan Medical Association
32
The Israeli Medical Association (IMA)
is an independent professional organiza-
tion representing Israeli physicians. The
IMA was established in 1912, and includes
among its members over 90% of the medi-
cal personnel working in Israel’s health
funds, hospitals, state institutions and pri-
vate clinics. The IMA is responsible for
establishing professional norms and ensur-
ing high standards of medicine in Israel
and is involved in shaping national health
policy, influencing the legislative process
and presenting the achievements of Israeli
medicine to the global healthcare commu-
nity. The IMA is similarly responsible for
overseeing physicians’ working conditions
and for formulating and clarifying rules of
medical ethics.
Regional and NMA news
tended to the south, cordially accompanied
by TMA’s member organizations Tainan and
Kaohsiung Medical Associations.
It is worth noting that prior to the Doctors’
Day programs, the TMA had arranged for
our guests to deliver speeches to the partici-
pants of the 5th Global Forum for Health
Leaders during 9th and 10th November.
The Forum was organized by Taiwan Joint
Commission on Hospital Accreditation and
sponsored by the Department of Health.
Five honorable speakers from overseas ex-
pressed their compliments at Doctor’s Day
Celebrations.
Disaster Management
On 8th August this year, southern Taiwan
was devastated by super-typhoon Morakot.
Large-scale mudflows and landslides brought
the death toll to 634. The TMA took im-
mediate action by setting up a disaster relief
working group to support the government’s
disaster management efforts. All physicians
were summoned to cooperate with local
health authorities and provide medical ser-
vices. Members of TMA were highly appre-
ciated for their voluntary services, donations
and sponsorship of affected areas.
During post disaster reconstruction and
rehabilitation, the TMA places priority on
consolidating resources and providing spe-
cialty care, adequate health information and
education, as well as financial, pharmaceuti-
cal and psychological support. To this end,
the TMA appealed to professional associa-
tions of physicians,lawyers,accountants and
architects to participate in helping alleviate
victims’ trauma. In the meantime, heartfelt
condolences from national medical associa-
tions in other countries were received with
gratitude.
Although almost 100 hospitals and clin-
ics in the typhoon-hit areas suffered from
various degrees of damages, they resumed
services without delay to ensure proper care
for people in need. TMA President Dr.
Ming-Been Lee, deeply concerned about
local TMA members as well as the victims,
traveled to the sites in November and De-
cember to console victims while urging the
medical community to continue services
and focus on rehabilitation.
The TMA delegation, led by President Dr.
Ming-Been Lee, visited indigenous people
in Taitung, an area hit severely by Typhoon
Morakot and short of medical resources.
Major Projects Granted From
Department of Health
Professional Autonomy
For two consecutive years the TMA re-
ceived the Bureau of National Health In-
surance delegation programme of Profes-
sional Autonomy Affairs under the Primary
Care Global Budget System. Professional
autonomy and point-value management
in the primary care community have re-
sulted in a better healthcare environment.
Achievements of the programme include:
1) enhanced quality of care; 2) health facili-
ties at the primary level received counseling;
3) response to complaints from patients;
4) participation in the planning of primary
care global budget payment system; 5) plan-
ning of and capacity building for personnel
in the review panel; and 6) improved medi-
cal service review practice.
Continuing Medical
Education Accreditation
The TMA also participated in the 2008 De-
partment of Health (DOH) Accreditation
Programme of Continuing Medical Edu-
cation (CME) in Medical Ethics, Medical
Regulation and Medical Quality. By the
end of 2008, we received 2,330 cases and
our high quality accreditation plans were
satisfactory to the DOH, course organizers
and physicians. We helped physicians ob-
tain necessary points to renew their licenses.
An accredited administrative platform was
established to analyze and review all CME
courses, and organize academic conferences
with partner institutions to improve both
teaching and learning.
In addition,we continued to act as the agen-
cy to accredit CME courses. We completed
accreditation of CME courses, academic
meetings and international symposium or-
ganized by medical schools, associations,
societies,teaching hospitals and other agen-
cies. Individual physicians’ application for
CME points were processed and accepted.
A special team was assigned as a liaison to
assist CME course providers and physicians
on the recipient side.
Ming-Been Lee, MD,
President of the Taiwan Medical Association
The Israeli Medical Association
33
Regional and NMA news
One of the major activities undertaken by
the IMA in recent years was a lengthy ar-
bitration process designed to raise physi-
cians’ salaries and implement reforms to
their working conditions. In recognition
of the serious legal, ethical and financial
costs of striking, the IMA agreed in July
2000, on behalf of all publicly employed
physicians, to give up the right to strike for
ten years in exchange for this mandatory
arbitration. The arbitration process only
began in 2005, and in 2008 it was decided
that doctors would receive a salary increase
of approximately 23.5%; however, no real
reforms on issues such as manpower and
continuing medical education were real-
ized.
Another recent and ongoing project initi-
ated by the IMA relates to the increas-
ingly troublesome phenomenon of violence
against physicians. The IMA approached
this problem on several fronts. For instance,
the IMA has proposed several bills in Par-
liament to prevent violence against medical
personnel, such as one bill intensifying the
punishment for those who attack medical
personnel and another allowing doctors to
refuse to treat previously violent patients,
except in emergency situations.
The IMA also appealed to the Supreme
Court to obligate the Ministry of Health to
implement an emergency plan as well as to
implement the permanent directives from
a report previously issued by the Director
General. The Supreme Court criticized the
Ministry of Health for not implementing
its own plan. Immediately following this
criticism, the Ministry of Health budgeted
2 million NIS to reduce violence against
physicians and Clalit Health fund, the larg-
est Health fund in Israel, budgeted 2.5 mil-
lion NIS for the same purpose.
In addition to the legal measures imple-
mented, the IMA manages an emergency
hotline for doctors who have been victims
of violence,providing immediate advice and
referrals. The IMA also contracts with a
professional security company that accom-
panies doctors who have been attacked and
appear to be in danger, and provides profes-
sional advice. In conjunction with a profes-
sional media company, the IMA produced
a video clip on the topic of violence against
physicians that was broadcast on Israeli
cable television.
Finally, the IMA partnered the pilot proj-
ect, “Hospitals without Violence” at Wolf-
son Hospital and advanced a pilot of mobile
emergency buttons in the operating room of
Sheba Medical Center. The IMA also initi-
ated a forum of all the bodies representing
workers in the health sector to contend to-
gether and to pressure decision makers to
deal with the problem of violence.
Another topic which the IMA chose to ad-
dress this year is that of physicians’ health.
Viewing the health of physicians as a pre-
requisite to the proper care of patients, the
IMA set up a hotline that provides confi-
dential referrals to doctors seeking medical
help in various fields. The IMA is also pre-
paring information booklets for employers
and physicians discussing issues related to
physician health and raising practical sug-
gestions such as: healthy food and exercise,
immunizations and periodic checkups, naps
during rotations, and making the workplace
“breastfeeding friendly”.
The IMA also developed several workshops
for coping strategies and burnout preven-
tion. A pilot workshop was held for resi-
dents at Soroka Hospital in Beersheva and
considered very successful.
The IMA has also been working on the key
issue of Inequalities in Health. In Israel, as
in many countries around the world, health
services are available and accessed different-
ly across geographic, economic and socio-
demographic lines, resulting in health dis-
parities. In order to combat this increasing
problem, the IMA convened a committee
which discussed the problem in depth and
produced a report on health inequalities in
Israel. Following this, several actions were
taken by the IMA including developing a
training programme to teach physicians
how to treat patients who are different from
themselves, a telephone survey to assess the
impact of health inequalities in Israel, and
meetings with government officials took
place.
This desire to improve the health of less for-
tunate populations is always at the forefront
of the IMA’s agenda. Another example can
be found in the clinic the IMA, along with
the Ministry of Health, established in No-
vember 2008 at the Tel Aviv central bus sta-
tion. The purpose of the clinic is to provide
for people who do not yet have legal status
and are therefore not receiving treatment
at regular health institutions; this includes
both refugees and those work immigrants
who do not have legal status or any sort of
health insurance. The IMA and the Min-
istry of Health opened the clinic, which
functions by way of donations and volunteer
doctors and is intended to provide primary
health care to the refugees. The clinic was
established as a temporary measure until
there is proper legislation regarding health
coverage for these populations.
Prof. Leonid Eidelman
President of Israeli Medical Association
Leonid Eidelman
34
Regional and NMA news
The Ethiopian Medical Association was
founded on July 20th 1961, when His Im-
perial Majesty Haile Selasie I graciously
granted a Royal charter to the Association
and consented to be Patron of the Associa-
tion. Its first constitution was promulgated
in the same year.  Expatriate doctors played
a prominent role in the early history and ac-
counted for the majority of its membership.
Dr. F. Hylander, Swedish nationality, was
the first president of EMA and Dr. Yo-
hannes Kibreth, Ethiopian, was elected as
the 2nd
president of EMA in 1962. The or-
ganization became a member of the WMA
in 1963 and is also founding member of the
Confederation of African Medical Associa-
tions & Societies (CAMAS).
Vision:
A healthy and prosperous Ethiopian com-
munity with access to quality health ser-
vices provided by physicians who have the
opportunity to continuously enhance their
professional capacity, exercise their rights
and enjoy the benefits of their profession,
and practice freely in an environment that
respects medical ethics.
Mission:
To ensure the rights and benefits of phy-
sicians through lobbying and advocacy, to
enhance their professional abilities through
continuous development of their medical
knowledge in service to their patients,and to
work with the government and other part-
ners for the improvement of quality health
services to the Ethiopian community.
Objectives:
1. To promote the professional excellence
of members in preventive and curative
medicine and medical research
2. To promote the science and art of medi-
cine and improve public health
3. To promote and maintain intellectual
and professional freedom
4. To provide professional and technical
advice to the Ministry of Health and
other concerned organizations
5. To publish the Ethiopian Medical Jour-
nal and other professional journals as
the need arises
6. To provide a forum for the exchange of
professional ideas, knowledge and expe-
rience among the members of EMA
7. To provide Continuing Medical Edu-
cation for all doctors practicing in
­Ethiopia
In pursuit of the above objectives, the EMA
holds annual medical conferences where
members exchange ideas, knowledge and
experience; publishes Ethiopian Medical
Journal quarterly; and provides continuing
medical education to update the knowledge
of its members.
During the last three years, the EMA has
reorganized the Secretariat,increased its ca-
pacity and worked closely with the Federal
Ministry of Health and International Orga-
nizations. Other accomplishments include:
In-house capacity building•
Development of a five-year Strategic•
Plan
Establishment of four branch offices•
Development and implementation of•
projects
Revision of the Constitution of EMA•
Collaborative activities with different•
stakeholders
Essential steps towards the realization of•
EMA’s future house
The projects EMA is implementing are:
Research-based incentive for physicians•
working in remote hospitals
Human resource capacity building to ac-•
celerate ART uptake in Ethiopia
Support of routine immunization services•
Infection prevention•
EMA is pleased to partner with WMA,
other sister associations and organizations
in implementing projects of mutual inter-
est.
Please visit our website: www.emaethiopia.org
Dr. Mahdi Bekri, Executive Director of
Ethiopian Medical Association
The Ethiopian Medical Association
Mahdi Bekri
EMA Executive Committee with Minister of
Federal Ministry of Health
EMA 44th
Annual Conference at United Na-
tion Conference center – Addis Ababa, 2008
35
Regional and NMA news
Jose Ramon Huerta Blanco
The Organización Médica Colegial of Spain
(OMC) (Spanish Medical Association) is
the institution formed by the 52 medical
colleges of Spain and is in charge of the ar-
rangement, regulation, control and defence
of the medical profession according to the
Spanish rules and regulations. Although
the medical colleges have been regulated
by Law since 1898, the General Council of
Medical Colleges of Spain was formed in
1921. This is the body which groups and
coordinates the provincial and autonomous
Medical Colleges, as public law corpora-
tions, that are an authority within the pro-
fession.
The OMC activities are focused on very
diverse areas, always related to the medi-
cal profession. Besides the habitual activi-
ties of record and professional control as
well as qualifications, the OMC promotes
continuous medical training activities for
which it has a specific Foundation. It also
has a Central Medical Ethics Commission
which not only studies the cases that it re-
ceives from the Medical Colleges, but also
carries out studies and documents about the
position of the medical profession in fun-
damental ethical questions that concern it.
Thus in the last months, it has updated its
positions on medical care at the end of life
and on the regulation of a conscience clause
for health care professionals who don’t want
to perform abortions.
The OMC has a digital journal “Doctors
and Patients” which maintains updated in-
formation about questions of medical health
care and social interest, but also of infor-
mation and interest for patients. Also the
OMC has approved the creation of a Social
Council to foster and to promote meetings
and collaboration with patients who are the
raison d’être of medicine.
In the last year the OMC has tightened
its bonds of collaboration and action with
the most representative medical entities of
Spain: the medical trade unions, the Con-
ference of Deans of Medical Universities,
the State Council of Medical Students, the
Federation of Spanish Medical Scientific
Associations and the National Commission
of Specialities in Health Sciences, integrat-
ing with them all what is known as the Fo-
rum of the Medical Profession.
In addition, the OMC is developing a wide
activity in defence of the medical associa-
tion and contributing its point of view to
the legal regulations. Our association un-
derstands that the association formula is the
one that best guarantees the social protec-
tion of patient’s interests, the fulfilment of
Ethics, the control and regulation of the
profession, which has been commended the
protection of an important asset: health.
The OMC is developing efforts and taking
measures to assure the conscience clause for
health care professionals when faced with
the modification of the Law on Abortion.
Also it undertakes intense actions to assure
that the authority to prescribe drugs is re-
served to health care professionals because
the competence to prescribe is inseparably
linked with the diagnosis for reasons of ef-
ficiency, quality and safety in health care.
Efforts are also being made in social and
health matters of general interest, promot-
ing numerous training and informative ac-
tions aimed at health care professionals and
the population at large,among which can be
highlighted information about Influenza A
(H1N1), the Effects of the Climate Change
on Health, the Prescription and the Ration-
al Use of Drugs.
Recertification of the competences of
health care professionals and reassociation
depending on the fulfilment of professional,
psychophysical criteria and of accredited
updating of professional competence is
another of the challenges that the Spanish
medical organisation has to face after 2010,
reinforcing the corporate commitment with
the patient and society and transparency to-
wards health care professionals and society.
The Spanish medical organisation has a
very extensive international collaboration.
It plays an active role in the World Medical
Association, European medical organisa-
tions like the CEOM (European Council
of Medical Orders) and organisations of
medical specialists (UEMS), general prac-
titioners (UEMO), hospital health care
professionals (AEHM), doctors in training
(PWG). The cooperation with the countries
of Latin America organised through the
FIEM (Latin-American Forum of Medical
Entities) is of special interest, without for-
getting the social and solidarity action for
which the OMC has formed a Solidarity
Foundation with the purpose of promot-
ing and channelling help and cooperation
for medical – health care in countries with
precarious health care and vulnerable and
needy populations.
Dr. Jose Ramon Huerta Blanco,
International Relations Coordinator
The Organización Médica Colegial
De España
36
Regional and NMA news
Jorge Carlos Jañez
As a consequence of the neoliberal policies
implemented, repetitive budget cuts have
damaged the social, political and institu-
tional situation not only in our country, but
in the entire Region.
Health services have been deteriorating
gradually, the public healthcare spending
is decreasing in terms of the income per
capita ratio, and the scarce resources had to
be adapted by giving importance to treat-
ment over prevention. At the same time,
new changes have been introduced in the
financial aspect, there is a rising tendency to
privatisation and the operating expenditure
belongs to the user now.
Within the framework of these neoliberal
policies, several reasons were stated which
privilege the following: expenditure is now
afforded by the users of the system, private
resources are excessively used and the public
services administration is decentralised.
In addition to the aforementioned, the sec-
tor shows an extreme sanitary anarchy, a
lack of coordination between the public and
the private sector, which results in the dou-
bling and superposition of services and the
low use of resources.
Social Security definancing is a consequence
of the unreleased unemployment rate. The
unemployed population lost their health in-
surance coverage which led to the overload
of Public Hospitals as well as a fall in the
private sector provision of services. As a re-
sult, doctors who perform in this subsector
have been directly affected.
Given that the infrastructure and the public
sector supplies are in bad condition, doctors
lack all kind of support before patients. The
latter not only demand a medical assistance
that doctors cannot provide on their own,
but also take legal action against them more
frequently. Thus, a patient’s right before an
undesired treatment result was turned into
the so-called “medical malpractice insur-
ance industry”.
It is even worse when faced by unrestrainted
relatives or the same patient, since they are
becoming more and more aggressive, and
may end up assaulting physically. Apart
from these unfortunate situations, the doc-
tor’s proletarianisation must also be men-
tioned. It is caused by several factors:
Professional Plethora which shows a doc-•
tor to patient ratio of approximately 360.
In some large places, big urban centres,
the ratio is 120 inhabitants per doctor.
Increase of professional medical licenses•
up to 5 times faster than the population.
No planning of geographical distribu-•
tion.
High percentage of specialists (80%, 70%•
out of this 80% are in the big urban cen-
tres).
After the proposal of the National Inte-
grated Health System in 1973, which was
abolished,and laws 23660/61of the Nation-
al Health Insurance (last essays on national
policies), there was a crisis in the service
provider which still continues, and signs in-
dicate that it will get worse.
This deep crisis demands a health system
reform in accordance with a STATE POLI-
CY under consensus of all participants, bas-
ing the system programme on the following
proposal:
Give priority to Primary Attention•
(Mother & Child Programmes, Special
Plans for the needed, etc.) as a response
to the emergency.
Complement all subsectors in order to•
shift the fragmenting system by using the
idle installed capacity.
Coverage based on an Obligatory Medi-•
cal Insurance.
State administration and regulation•
which comprises:
High Complexity–
High Medical Technology–
Medicine–
Regulation of the professional practice•
which comprises:
Adaptation of programmes of study in–
the Medical Schools
Planning the number of students who–
enter Schools according to the System
needs
Planning access to the work source–
Programming the geographical distri—
bution
Professional certification and recertifi—
cation
Professional Career–
Regulation of specialisations–
Dr. Jorge Carlos Jañez,
President of Medical Confederation
of the Argentine Republic
Medical Confederation
of the Argentine Republic
37
Climate change
The COP15 – Conference of the Parties –
has been the talk of Copenhagen and the
rest of the World, since December last year
when the city was transformed into a giant
hotel with a display of leaders from all over
the world. Copenhagen was meant to be
the place where an agreement of tremen-
dous importance to our planet should be
realized.
The World Medical Association worked
hard to gain access to the COP 15 NGO
conference by applying for observer status
to the UNFCC. In the end, access was not
granted and WMA had to pursue other
means of participating in the negotiations.
Fortunately HEAL – the Health and En-
vironment Alliance – offered to include Dr.
Jens Winther Jensen and CEO Bente Hyl-
dahl Fogh from the Danish Medical As-
sociation in its delegation, to represent the
WMA.
The Health and Environment Alliance is a
European umbrella organisation, based in
Brussels, working for health and the envi-
ronment. At the COP15, HEAL had in-
vited a number of NGOs to join in their
efforts to place health on the agenda at the
NGO conference of the COP15.
The HEAL delegation included: the
Standing Committee for European Doc-
tors (CPME), International Federation for
Medical Student’s Associations (IMFSA),
European Public Health Alliance, Climate
and Health Council, Health Care Without
Harm, Harvard Medical School, Medsin-
UK and others.
HEAL succeeded in public promotion of
its agenda during the COP15. An article
was published in the NGO Newsletter on
climate negotiations “ECO”. The delega-
tion also posted information on the “Pre-
scription for a Healthy Planet” website,
where health professionals are encouraged
to sign up at: www.climateandhealthcare.org.
Furthermore,WHO delegates attended one
of the HEAL side events. It was an oppor-
tunity for HEAL to present the views of
the medical community on the importance
of health impacts on climate change.
The HEAL delegation, as well as other del-
egates to the NGO conference, had mas-
sive problems actually gaining access to the
conference venue,including standing in line
outside for about six hours in the winter
cold, as the number of accredited delegates
to the UNFCC far outweighed its capac-
ity. In the end, the WMA delegates did not
gain access to the Center, but invited the
HEAL delegation for a debriefing at the
Danish Medical Association building on
the last day of the official NGO conference,
the 17th
of December 2009.
At the debriefing, participants agreed that
the conference was not a success, given
the fact that no goal for reduction of CO2
emissions was reached, but valuable lessons
had been learned. The International Medi-
cal Students’Association had formed strong
relations with the WHO and the impor-
tance of building strong alliances before ar-
riving at the COP was stressed many times
during the meeting.The need to be very ac-
curate about the cost and means of turning
proposals and ideas into working initiatives
was also underlined. This applies to policy
as well. For example, when WMA recom-
mends in a policy declaration that the public
health systems should be strengthened, the
recommendation must be accompanied by
concrete, detailed initiatives if the message
is to be received and understood by decision
makers.
The recommendation from the HEAL
delegation in view of the next COP16 in
Mexico was therefore to:
“Build relations with key decision makers
well in advance of the event, build strong
alliances with other health professionals
such as nurses, midwives, medical students
as well as journalists before the next COP
to ensure that the message we wish to con-
vey is heard, but, perhaps most importantly:
be very specific about the goals we wish to
achieve and the cost implications.”
Success or failure? The delegation was hope-
ful that the next COP will be more effective
given that valuable work has been done to
form a base to take decisions and lessons
have been learned by the world leaders.
The challenges are still in front of us. The
positive relationship between reducing
green house gasses and obtaining better
health must be pursued by world leaders
and by doctors.
Bente Hyldahl Fogh, Chief executive officer,
Danish Medical Association,
Christina Lumby Rasmussen,
Danish Medical Association
COP 15 – success or failure?
38
Climate change
“Climate change is the greatest global health
threat of the 21st
century”
When the four of us arrived in Copenhagen
last Saturday, mid-way through negotia-
tions, we were shocked to see that concepts
of Global Health equity were absent from
the UNFCCC’s text. In 1992, with the cre-
ation of the UNFCCC, human health was
described as one of guiding principles of the
framework. Nineteen years on, at the 15th
Conference of the Parties, we see no such
mention of health.
As medical and global health students, and
members of the International Federation of
Medical Students’ Associations (IFMSA),
this fact was of great concern to us. We are
convinced that health should be placed at
the centre of negotiations, providing an ef-
fective framework for a successful global
deal. Our views were supported by three
other delegations (the Health & Environ-
ment Alliance,Health Care Without Harm,
and the World Health Organisation), with
which we formed an unofficial coalition.
The Bella centre (the chosen venue for the
‘historic’ conference) was enormous, and
full of negotiating teams, members of civil
society, security and UN staff, all busy try-
ing to culminate the last year of work into
what could hopefully be a successful round
of negotiations. If we were to be effective,
we had to be organised, and smart with the
few precious days we had in Copenhagen.
We set out to promote the concept of health
within the UNFCCC negotiations, and
build lasting relationships and our own ca-
pacity for coming COPs. We did just that.
We wrote letters to, and met with country
delegations who were either most affected
by climate change, had brought their health
ministers to the negotiations, or had already
included ‘health’ as a central theme in their
national statement. We encouraged them to
speak out in plenary, attend our side-events
and actions, and plan to put them in contact
with medical students and clinicians from
their country interested in climate change.
This was highly successful, and we received
interviews and statements from many coun-
tries around the world (including the UK,
France, Ghana, Burkina Faso, Indonesia,
the Maldives, and the Netherlands, among
others). All the while we were feeding in-
formation to our fellow students in the IF-
MSA through blogs, videos, interviews and
daily summaries.
On Wednesday the 16th
, we staged a UN
approved ‘Action’ with the Health Environ-
ment Alliance and Health Care Without
Harm. This involved a visit from a ‘surprise’
doctor, vocally teaching a ward round of
medical students about the correlations be-
tween climate change and health. Not only
has climate change been revealed to be “The
greatest global health threat of the 21st
cen-
tury”(The Lancet Series), but recent studies
have shown that there are co-benefits for
health associated with the mitigation of cli-
mate change.The doctor presented the con-
ference with our “Prescription for a Healthy
Planet”, imploring the health sector to par-
ticipate in the debate. The event was held
within the Bella centre, received significant
media coverage from national and inter-
national sources, and was well attended by
various health delegations, including the
WHO.
With the conclusion of the conference, we
sat down and asked ourselves,“What next?”
Negotiations were unsuccessful, more work
was needed, but we were not disheartened –
we were left wanting more.
We had covered significant ground, estab-
lished links with like-minded organisations,
and people were starting to mention human
health when they spoke of climate change.
But if we are ever to be successful, we need
the international health community to ac-
tively engage in discussion.
We require further research and data high-
lighting the economic benefits of health
and climate change mitigation. We plan to
connect students with the health and envi-
ronment ministers we met, as well as with
healthcare professionals currently active in
this field. Most importantly though, we will
learn from this experience, further educate
ourselves, and build capacity for COP16 in
Mexico.
One thing is certain, we will be back.
IFMSA Delegation to the UNFCCC COP15,
Copenhagen – Nick Watts (Australia), Jonny
Currie (UK), Guppi Bola (UK), Mori
Mansouri (UK), Yorgos Polychronidis (Greece)
Written by Nick Watts
39
WMA news
Order of Physicians of Albania (OPA)
Rr. Dibres. Poliklinika Nr.10, Kati 3
Tirana
ALBANIA
Tel/Fax: (355) 4 2340 458
E-mail: albmedorder@albmail.com
Website: www.umsh.org
Col’legi de Metges
C/Verge del Pilar 5,
Edifici Plaza 4t. Despatx 11
500 Andorra La Vella
ANDORRA
Tel: (376) 823 525
Fax: (376) 860 793
E-mail: coma@andorra.ad
Website: www.col-legidemetges.ad
Ordem dos Médicos de Angola (OMA)
Rua Amilcar Cabral 151-153
Luanda
ANGOLA
Tel. (244) 222 39 23 57
Fax (221) 222 39 16 31
E-mail: secretariatdormed@gmail.com
Website: www.ordemmedicosangola.com
Confederación Médica de la República
Argentina
Av. Belgrano 1235
Buenos Aires 1093
ARGENTINA
Tel/Fax: (54-11) 4381-1548 / 4384-5036
E-mail: comra@confederacionmedica.com.ar
Website: www.comra.health.org.ar
Armenian Medical Association
P.O. Box 143
Yerevan 375 010
REPUBLIC OF ARMENIA
Tel. (3741) 53 58 68
Fax. (3741) 53 48 79
E-mail: info@armeda.am
Website: www.armeda.am
Australian Medical Association
P.O. Box 6090
Kingston, ACT 2604
AUSTRALIA
Tel: (61-2) 6270 5460
Fax: (61-2) 6270 5499
E-mail: ama@ama.com.au
Website: www.ama.com.au
Österreichische Arztekammer
(Austrian Medical Chamber)
Weihburggasse 10-12 – P.O. Box 213
1010 Wien
AUSTRIA
Tel: (43-1) 514 06 64
Fax: (43-1) 514 06 933
E-mail: international@aerztekammer.at
m.reisinger@aerztekammer.at
Website: www.aerztekammer.at
Azerbaijan Medical Association
P.O. Box 16
AZE 1000, Baku
REPublic OF Azerbaijan
Tel.(99 450) 328 18 88
Fax. (99 412) 431 88 66
E-mail: info@azmed.az – azerma@hotmail.com
Website: www.azmed.az
Medical Association of the Bahamas
P.O. Box N-3125
MAB House-6th Terrace Centreville
Nassau,
Bahamas
Tel.: (242) 328 1858
Fax: (242) 328 1857
E-mail: medassocbah@gmail.com
Bangladesh Medical Association
BMA Bhaban 5/2 Topkhana Road
Dhaka 1000
Bangladesh
Tel. (880) 2-9568714 / 9562527
Fax. (880) 2 9566060 / 9562527
E-mail: bma@aitlbd.net
Association Belge des Syndicats
Médicaux
Chaussée de Boondael 6, bte 4
1050 Bruxelles
BELGIUM
Tel: (32-2) 644 12 88
Fax: (32-2) 644 15 27
E-mail: absym.bvas@euronet.be
Website: www.absym-bvas.be
Colegio Médico de Bolivia
Calle Ayacucho 630
Tarija
BOLIVIA
Fax. (591) 4 666 3569
E-mail: colmedbol_tjo@hotmail.com
Website: www.colegiomedicodebolivia.org.bo
Associaçao Médica Brasileira
R. Sao Carlos do Pinhal 324 – Bairro Bela
Vista
Sao Paulo SP – CEP 01333-903
BRAZIL
Tel. (55-11) 3178 6810
Fax. (55-11) 3178 6830
E-mail: presidente@amb.org.br
Website: www.amb.org.br
Bulgarian Medical Association
15, Acad. Ivan Geshov Blvd.
1431 Sofia
BULGARIA
Tel: (359-2) 954 11 81
Fax: (359-2) 954 11 86
E-mail: blsus@mail.bg
Website: www.blsbg.com
Canadian Medical Association
P.O. Box 8650
1867 Alta Vista Drive
Ottawa, Ontario K1G 3Y6
CANADA
Tel: (1-613) 731 8610 ext. 2236
Fax: (1-613) 731 1779
E-mail: karen.clark@cma.ca
Website: www.cma.ca
Ordem Dos Medicos du Cabo Verde (OMCV)
Avenue OUA N° 6 – B.P. 421
Achada Santo António
Ciadade de Praia-Cabo Verde
CABO VERDE
Tel. (238) 262 2503
Fax (238) 262 3099
E-mail: omecab@cvtelecom.cv
Website: www.ordemdosmedicos.cv
Colegio Médico de Chile
Esmeralda 678 – Casilla 639
Santiago
CHILE
Tel: (56-2) 4277800
Fax: (56-2) 6330940 / 6336732
E-mail: rdelcastillo@colegiomedico.cl
Website: www.colegiomedico.cl
Chinese Medical Association
42 Dongsi Xidajie
Beijing 100710
CHINA
Tel: (86-10) 8515 8136
Fax: (86-10) 8515 8551
E-mail: intl@cma.org.cn
Website: www.chinamed.com.cn
Federación Médica Colombiana
Carrera 7 N° 82-66, Oficinas 218/219
Santafé de Bogotá, D.E.
COLOMBIA
Tel./Fax: (57-1) 8050073
E-mail: federacionmedicacolombiana@
encolombia.com
Website: www.fmc.encolombia.com
Ordre des Médecins du Zaire
B.P. 4922
Kinshasa – Gombe
DEMOCRATIC REP. OF CONGO
Tel: (243-12) 24589
Unión Médica Nacional
Apartado 5920-1000
San José
COSTA RICA
Tel: (506) 290-5490
Fax: (506) 231 7373
E-mail: unmedica@racsa.co.cr
Croatian Medical Association
Subiceva 9
10000 Zagreb
CROATIA
Tel: (385-1) 46 93 300
Fax: (385-1) 46 55 066
E-mail: hlz@email.htnet.hr
Website: www.hlk.hr/default.asp
Colegio Médico Cubano Libre
P.O. Box 141016
Coral Gables, FL 33114-1016
UNITED STATES
717 Ponce de Leon Boulevard
Coral Gables, FL 33134
Tel: (1-305) 446 9902/445 1429
Fax: (1-305) 4459310
Cyprus Medical Association (CyMA)
14 Thasou Street
1087 Nicosia
CYPRUS
Tel. (357) 22 33 16 87
Fax: (357) 22 31 69 37
E-mail: cyma@cytanet.com.cy
Czech Medical Association
J.E. Purkyne
Sokolská 31 – P.O. Box 88
120 26 Prague 2
CZECH REPUBLIC
Tel: (420) 224 266 201-4
Fax: (420) 224 266 212
E-mail: czma@cls.cz
Website: www.cls.cz
Danish Medical Association
9 Trondhjemsgade
2100 Copenhagen 0
Denmark
Tel: (45) 35 44 82 29
Fax: (45) 35 44 85 05
E-mail: er@dadl.dk, cc: clr@dadl.dk
Website: www.laeger.dk
Egyptian Medical Association
“Dar El Hekmah”
42, Kasr El-Eini Street
Cairo
Egypt
Tel: (20-2) 3543406
Colegio Médico de El Salvador
Final Pasaje N° 10
Colonia Miramonte
San Salvador
EL SALVADOR, C.A.
Tel: (503) 260-1111, 260-1112
Fax: (503) 260-0324
E-mail: comcolmed@telesal.net / marnuca@
hotmail.com
Estonian Medical Association (EsMA)
Pepleri 32
51010 Tartu
ESTONIA
Tel: (372) 7 420 429
Fax: (372) 7 420 429
E-mail: eal@arstideliit.ee
Website: www.arstideliit.ee
Ethiopian Medical Association
P.O. Box 2179
Addis Ababa
ETHIOPIA
Tel: (251-1) 158174
Fax: (251-1) 533742
E-mail: ema.emj@telecom.net.et / ema@eth.
healthnet.org
Website: www.emaethiopia.org
Fiji Medical Association
304 Wainamu Road
G.P.O. Box 1116
Suva
FIJI ISLANDS
Tel. (679) 3315388
Fax. (679) 3315388
E-mail: fma@unwired.com.fj
WMA Directory of Constituent Members
40
WMA news
Finnish Medical Association
P.O. Box 49
00501 Helsinki
FINLAND
Tel: (358-9) 393 091
Fax: (358-9) 393 0794
E-mail: fma@fimnet.fi
Website: .www.medassoc.fi
Association Médicale Française
180, Blvd. Haussmann
75389 Paris Cedex 08
FRANCE
Tel: (33) 1 53 89 32 41
E-mail: deletoile.sylvie@cn.medecin.fr
Georgian Medical Association
7 Asatiani Street
0177 Tbilisi
GEORGIA
Tel. (995 32) 398686
Fax. (995 32) 396751 / 398083
E-mail. gma@posta.ge
Website: www.gma.ge
Bundesärztekammer
(German Medical Association)
Herbert-Lewin-Platz 1
10623 Berlin
GERMANY
Tel: (49-30) 4004 56 360
Fax: (49-30) 4004 56 384
E-mail: international@baek.de
Website: www.baek.de
Ghana Medical Association
P.O. Box 1596
Accra
GHANA
Tel. (233-21) 670510 / 665458
Fax. (233-21) 670511
E-mail: gma@dslghana.com
Website: www.ghanamedassn.org
Association Médicale Haitienne
1ère
Av. du Travail #33 – Bois Verna
Port-au-Prince
HAITI, W.I.
Tel. (509) 2244 – 32
Fax:(509) 2244 – 50 49
E-mail: secretariatamh@gmail.com
Website: www.amhhaiti.net
Hong Kong Medical Association, China
Duke of Windsor Building
5th Floor
15 Hennessy Road
HONG KONG
Tel: (852) 2527-8285
Fax: (852) 2865-0943
E-mail: hkma@hkma.org
Website: www.hkma.org
Association of Hungarian Medical
Societies (MOTESZ)
Nádor u. 36 – PO.Box 145
1051 Budapest
HUNGARY
Tel: (36-1) 312 3807 – 312 0066
Fax: (36-1) 383-7918
E-mail: international@motesz.hu
Website: www.motesz.hu
Icelandic Medical Association
Hlidasmari 8
200 Kópavogur
ICELAND
Tel: (354) 864 0478
Fax: (354) 5 644106
E-mail: icemed@icemed.is
Indian Medical Association
Indraprastha Marg
New Delhi 110 002
INDIA
Tel: (91-11) 23370009/23378819/23378680
Fax: (91-11) 23379178/23379470
E-mail: imawmaga2009@gmail.com
Website: www.imanational.com
Indonesian Medical Association
Jl. G.S.S.Y. Ratulangie N° 29 Menteng
Jakarta 10350
INDONESIA
Tel: (62-21) 3150679 / 3900277
Fax: (62-21) 390 0473
E-mail: pbidi@idola.net.id
Website:www.idionline.org
Irish Medical Organisation
10 Fitzwilliam Place
Dublin 2
IRELAND
Tel: (353-1) 6767273
Fax: (353-1) 662758
E-mail: imo@imo.ie
Website: www.imo.ie
Israel Medical Association
2 Twin Towers, 35 Jabotinsky St.
P.O. Box 3566, Ramat-Gan 52136
ISRAEL
Tel: (972-3) 610 0444
Fax: (972-3) 575 0704
E-mail michelle@ima.org.il
Website: www.ima.org.il
Ordre National des Médecins de la Côte
d’Ivoire (ONMCI)
Cocody Cité des Arts, Bât. U1, Esc.D,
RdC, Porte n°1
BP 1584
Abidjan 01
IVORY COAST
Tel. (225) 22 48 61 53 /22 44 30 78/
Tel. (225) 02 02 44 01 /08 14 55 80
Fax: (225) 22 44 30 78
E-mail: onmci@yahoo.fr
Website: www.onmci.org
Japan Medical Association
2-28-16 Honkomagome, Bunkyo-ku
Tokyo 113-8621
JAPAN
Tel: (81-3) 3946 2121/3942 6489
Fax: (81-3) 3946 6295
E-mail: jmaintl@po.med.or.jp
Website: www.med.or.jp
Association of Medical Doctors of
Kazakhstan
117/1 Kazybek bi St.,
Almaty
KAZAKHSTAN
Tel. (7-327 2) 624301 / 2629292
Fax. (7-327 2) 623606
E-mail: doktor_sadykova@mail.ru
Korean Medical Association
302-75 Ichon 1-dong, Yongsan-gu
Seoul 140-721
REP. OF KOREA
Tel: (82-2) 794 2474
Fax: (82-2) 793 9190/795 1345
E-mail: intl@kma.org
Website: www.kma.org
Kuwait Medical Association
P.O. Box 1202
Safat 13013
KUWAIT
Tel. (965) 5333278, 5317971
Fax. (965) 5333276
E-mail: kma@kma.org.kw
alzeabi@hotmail.com
Latvian Physicians Association
Skolas Str. 3
Riga 1010
Latvia
Tel: (371) 67287321 / 67220661
Fax: (371) 67220657
E-mail: lab@arstubiedriba.lv
Website: www.arstubiedriba.lv
Liechtensteinische Ärztekammer
Postfach 52
9490 Vaduz
LIECHTENSTEIN
Tel: (423) 231 1690
Fax. (423) 231 1691
E-mail: office@aerztekammer.li
Website: www.aerzte-net.li
Lithuanian Medical Association
Liubarto Str. 2
2004 Vilnius
LITHUANIA
Tel./Fax. (370-5) 2731400
E-mail: lgs@takas.lt
Website: www.lgs.lt
Association des Médecins et
Médecins Dentistes du Grand-
Duché de Luxembourg (AMMD)
29, rue de Vianden
2680 Luxembourg
LUXEMBOURG
Tel: (352) 44 40 33 1
Fax: (352) 45 83 49
E-mail: secretariat@ammd.lu
Website: www.ammd.lu
Macedonian Medical Association
Dame Gruev St. 3
P.O. Box 174
91000 Skopje
MACEDONIA
Tel: (389-2) 3162 577
Fax: (389-91) 232577
E-mail: mld@unet.com.mk
Society of Medical Doctors of Malawi (SMD)
Post Dot Net, PO Box 387, Crossroads
Lilongwe Malawi
30330 Lilongwe
MALAWI
E-mail: dlungu@sdnp.org.mw
Website : www.smdmalawi.org
Malaysian Medical Association
4th Floor, MMA House
124 Jalan Pahang
53000 Kuala Lumpur
MALAYSIA
Tel: (60-3) 4041 1375
Fax: (60-3) 4041 8187
E-mail: info@mma.org.my / president@mma.
org.my
Website: www.mma.org.my
Ordre National des Médecins du Mali
(ONMM)
Hôpital Gabriel Touré
Cour du Service d’Hygiène
BP E 674
Bamako
MALI
Tel. (223) 223 03 20/ 222 20 58/
E-mail: cnommali@gmail.com
Website: www.keneya.net/cnommali.com
Medical Association of Malta
The Professional Centre
Sliema Road, Gzira GZR 06
MALTA
Tel: (356) 21312888
Fax: (356) 21331713
E-mail: martix@maltanet.net
Website: www.mam.org.mt
Colegio Medico de Mexico (FENACOME)
Adolfo Prieto #812
Col.Del Valle
D. Benito Juárez
Mexico 03100
MEXICO
Tel. 52 55 5543 8989
Fax. 52 55 5543 1422
E-mail: fenacome_relint@teyco.com.mx
Website: www.cmm-fenacome.org
Medical Association of Namibia
403 Maerua Park – POB 3369
Windhoek
NAMIBIA
Tel. (264) 61 22 4455
Fax. (264) 61 22 4826
E-mail: man.office@iway.na
Nepal Medical Association
Siddhi Sadan, Post Box 189
Exhibition Road
Katmandu
NEPAL
Tel. (977 1) 4225860, 4231825
Fax. (977 1) 4225300
E-mail: nma@healthnet.org.np
Royal Dutch Medical Association
P.O. Box 20051
3502 LB Utrecht
NETHERLANDS
Tel: (31-30) 282 38 28
Fax: (31-30) 282 33 18
E-mail: j.bouwman@fed.knmg.nl
Website: www.knmg.nl
www.artsennet.nl
New Zealand Medical Association
P.O. Box 156, 26 The Terrace
Wellington 1
NEW ZEALAND
Tel: (64-4) 472 4741
Fax: (64-4) 471 0838
E-mail: lianne@nzma.org.nz
41
WMA news
Website: www.nzma.org.nz
Nigerian Medical Association
74, Adeniyi Jones Avenue Ikeja
P.O. Box 1108, Marina
Lagos
NIGERIA
Tel: (234-1) 480 1569, 876 4238
Fax: (234-1) 493 6854
E-mail: info@nigeriannma.org
Website: www.nigeriannma.org
Norwegian Medical Association
P.O.Box 1152 sentrum
0107 Oslo
NORWAY
Tel: (47) 23 10 90 00
Fax: (47) 23 10 90 10
E-mail: ellen.pettersen@legeforeningen.no
Website: www.legeforeningen.no
Asociación Médica Nacional
de la República de Panamá
Apartado Postal 2020
Panamá 1
PANAMA
Tel: (507) 263 7622 /263-7758
Fax: (507) 223 1462
Fax modem: (507) 223-5555
E-mail: amenalpa@cwpanama.net
Colegio Médico del Perú
Malecón Armendáriz N° 791
Miraflores
Lima
PERU
Tel: (51-1) 241 75 72
Fax: (51-1) 242 3917
E-mail: prensanacional@cmp.org.pe
Website: www.cmp.org.pe
Philippine Medical Association
2/F Administration Bldg.
PMA Compound, North Avenue
Quezon City 1105
PHILIPPINES
Tel: (63-2) 929-63 66
Fax: (63-2) 929-69 51
E-mail: philmedas@yahoo.com
Website: www.pma.com.ph
Polish Chamber of Physicians and Dentists
(Naczelna Izba Lekarska)
110 Jana Sobieskiego
00-764 Warsaw
POLAND
Tel. (48) 22 55 91 300/324
Fax: (48) 22 55 91 323
E-mail: sekretariat@hipokrates.org
Website: www.nil.org.pl
Ordem dos Médicos
Av. Almirante Gago Coutinho, 151
1749-084 Lisbon
PORTUGAL
Tel: (351-21) 842 71 00/842 71 11
Fax: (351-21) 842 71 99
E-mail: intl@omcn.pt
Website: www.ordemdosmedicos.pt
Romanian Medical Association
Str. Ionel Perlea, nr 10,
Sect. 1, Bucarest
ROMANIA
Tel: (40-21) 460 08 30
Fax: (40-21) 312 13 57
E-mail: amr@itcnet.ro
Website: www.ong.ro/ong/amr/
Russian Medical Society
Udaltsova Street 85
119607 Moscow
RUSSIA
Tel./Fax (7-495) 734-12-12
Tel. (7-495) 734-11-00/(7-495)734 11 00
E-mail: info@russmed.ru
Website: www.russmed.ru/eng/who.htm
Samoa Medical Association
Tupua Tamasese Meaole Hospital
Private Bag – National Health Services
Apia
SAMOA
Tel. (685) 778 5858
E-mail: vialil_lameko@yahoo.com
Ordre National des Médecins du Sénégal
(ONMS)
Institut d’Hygiène Sociale (Polyclinique)
BP 27115
Dakar
SENEGAL
Tel. (221) 33 822 29 89
Fax: (221) 33 821 11 61
Website: www.ordremedecins.sn
Singapore Medical Association (SiMA)
Alumni Medical Centre, Level 2
2 College Road
Singapore 169850
Tel. (65) 6223 1264
Fax. (65) 6224 7827
E-mail. sma@sma.org.sg
Website: www.sma.org.sg
Slovak Medical Association
Cukrova 3
813 22 Bratislava 1
SLOVAK REPUBLIC
Tel. (421) 5292 2020
Fax. (421) 5263 5611
E-mail: secretarysma@ba.telecom.sk
Website: www.sls.sk
Slovenian Medical Association
Komenskega 4
61001 Ljubljana
SLOVENIA
Tel. (386-61) 323 469
Fax: (386-61) 301 955
Somali Medical Association
7 Corfe Close
Hayes
Middlesex UB4 0XE
United Kingdom
E-mail: drdalmar@yahoo.co.uk
The South African Medical Association
P.O. Box 74789, Lynnwood Rydge
0040 Pretoria
SOUTH AFRICA
Tel: (27-12) 481 2045
Fax: (27-12) 481 2100
E-mail: sginterim@samedical.org
Website: www.samedical.org
Consejo General de Colegios Médicos
Plaza de las Cortes 11, 4a
Madrid 28014
SPAIN
Tel: (34-91) 431 77 80
Fax: (34-91) 431 96 20
E-mail: internacional@cgcom.es
Website: www.cgcom.es
Swedish Medical Association
(Villagatan 5)
P.O. Box 5610
SE – 114 86 Stockholm
SWEDEN
Tel: (46-8) 790 35 01
Fax: (46-8) 10 31 44
E-mail: info@slf.se
Website: www.lakarforbundet.se
Fédération des Médecins Suisses (FMH)
Elfenstrasse 18 – C.P. 170
3000 Berne 15
SWITZERLAND
Tel. (41-31) 359 11 11
Fax. (41-31) 359 11 12
E-mail: info@fmh.ch
Website: www.fmh.ch
Taiwan Medical Association
9F, No 29, Sec.1
An-Ho Road
Taipei 10688
Taiwan
Tel: (886-2) 2752-7286
Fax: (886-2) 2771-8392
E-mail: intl@tma.tw
Website: www.tma.tw
Medical Association of Thailand
2 Soi Soonvijai
New Petchburi Road, Huaykwang Dist.
Bangkok 10310
THAILAND
Tel: (66-2) 314 4333/318-8170
Fax: (66-2) 314 6305
E-mail: math@loxinfo.co.th
Website: www.medassocthai.org
Conseil National de l’Ordre
des Médecins de Tunisie
16, rue de Touraine
1002 Tunis
TUNISIA
Tel: (216-71) 792 736/799 041
Fax: (216-71) 788 729
E-mail: cnom@planet.tn
Turkish Medical Association
GMK Bulvari
Şehit Daniş Tunaligil Sok. N° 2 Kat 4
Maltepe 06570
Ankara
TURKEY
Tel: (90-312) 231 31 79
Fax: (90-312) 231 19 52
E-mail: Ttb@ttb.org.tr
Website: www.ttb.org.tr
Uganda Medical Association
Plot 8, 41-43 circular rd.
P.O. Box 29874
Kampala
UGANDA
Tel. (256) 41 321795
Fax. (256) 41 345597
E-mail. myers28@hotmail.com
Ukrainian Medical Association (UkMA)
7 Eva Totstoho Street
PO Box 13
Kyiv 01601
UKRAINE
Tel. (380) 50 355 24 25
Fax: (380) 44 501 23 66
E-mail: sfult@ukr.net
Website: www.sfult.org.ua
British Medical Association
BMA House, Tavistock Square
London WC1H 9JP
UNITED KINGDOM
Tel: (44-207) 387-4499
Fax: (44- 207) 383-6400
Website: www.bma.org.uk
American Medical Association
515 North State Street
Chicago, Illinois 60654
UNITED STATES
Tel: (1-312) 464 5291 / 464 5040
Fax: (1-312) 464 5973
E.mail: ellen.waterman@ama-assn.org
Website: www.ama-assn.org
Sindicato Médico del Uruguay
Bulevar Artigas 1515
CP 11200 Montevideo
URUGUAY
Tel: (598-2) 401 47 01
Fax: (598-2) 409 16 03
E-mail: secretaria@smu.org.uy
Associazione Medica del Vaticano
00120 Città del Vaticano
VATICAN STATE
Tel: (39-06) 69879300
Fax: (39-06) 69883328
E-mail: servizi.sanitari@scv.va
Federacion MedicaVenezolana
Av. Orinoco con Avenida Perija
Urbanizacion Las Mercedes
Caracas 1060 CP
VENEZUELA
Website: www.federacionmedicavenezolana.org
Vietnam Medical Association (VGAMP)
68A Ba Trieu-Street, Hoau Kiem District
Hanoi
VIETNAM
Tel: (84) 4 943 9323
Fax: (84) 4 943 9323
Website: www.masean.org/vietnam
Zimbabwe Medical Association
P.O. Box 3671
Harare
ZIMBABWE
Tel. (263-4) 791553
Fax. (263-4) 791561
E-mail: zima@zol.co.zw
Website: www.zima.org.zw
WMA news
No time for depression – A busy year ahead for WMA . . . . . . . . 1
WMA Conference in Riga. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Doctors for the environment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
“Physicians suffering from silent desperation”,
says WMA leader. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Task-shifting or task-sharing? –
Reflections from within the European Union (EU) . . . . . . . . . . 4
Multi-Drug Resistant TB in prisons. . . . . . . . . . . . . . . . . . . . . . . 6
Neuroimaging and the birth of cognitive neuroscience. . . . . . . . 10
Action alertCountry-level support needed now
for the global strategy to reduce the harmful use of alcohol. . . . . . . . . 12
Response of the Global Alcohol Policy Alliance to WHO’s. . . . 13
Reflections on the Standing Committee
of European Doctors’ (CPME). . . . . . . . . . . . . . . . . . . . . . . . . . 14
The European Patients’ Forum (EPF). . . . . . . . . . . . . . . . . . . . . 18
UEMO – A common European voice
for General Practicioners/Family Physicians. . . . . . . . . . . . . . . . 21
Gearing up for emergencies –
a vital component to our nation’s health . . . . . . . . . . . . . . . . . . 24
Report of the 26th
CMAAO Bali Congress. . . . . . . . . . . . . . . . . 25
What can medical journals do for global health? . . . . . . . . . . . . 26
The right to health as a bridge to peace in the Middle East. . . . 29
Organization of the Professional Self-Government
of Physicians and Dentists in Poland . . . . . . . . . . . . . . . . . . . . . 30
Messages from Taiwan Medical Association. . . . . . . . . . . . . . . . 31
The Israeli Medical Association. . . . . . . . . . . . . . . . . . . . . . . . . . 32
The Ethiopian Medical Association . . . . . . . . . . . . . . . . . . . . . . 34
The Organización Médica Colegial De España . . . . . . . . . . . . . 35
Medical Confederation of the Argentine Republic. . . . . . . . . . . 36
COP 15 – success or failure?. . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
“Climate change is the greatest
global health threat of the 21st
century”. . . . . . . . . . . . . . . . . . . . 38
WMA Directory of Constituent Members. . . . . . . . . . . . . . . . . 39
WMA General Assembly, New Delhi
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